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pdfE2.1 EXPANDED MENU SURVEY BOOKLET: INSTRUCTIONS,
EXAMPLE FORMS, AND FORMS (GROUP 3)
Menu Survey Screener - Expanded (Group 3)
Daily Meal Counts Form (Group 3)
Reimbursable Foods Form - Breakfast (Group 3)
Reimbursable Foods Form - Lunch (Group 3)
Recipe Form - Expanded (Group 3)
Self-Serve/Made to Order Bar Form - Expanded (Group 3)
NSLP Afterschool Snack Form - Expanded (Group 3)
CACFP Afterschool Snack and Supper Form (Group 3)
Non-Reimbursable Foods Form (Group 3)
A la Carte Food Checklist (Group 3)
Non-Reimbursable Foods Inventory (Group 3)
Menu Survey Enhancements Administered through the Electronic
Menu Survey (EMS) - Expanded (Group 3)
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OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
School Nutrition and Meal Cost
Study-II
Instructions for the
Menu Survey (Expanded)
Sponsored by:
U.S. Department of Agriculture
Food and Nutrition Service
The Expanded Menu Survey will be administered as a booklet that contains each of the instruments listed on the
appendix page. Therefore, the total burden for all instruments in the Expanded Menu Survey is included in the
burden statement below.
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 10 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-xxxx). Do not return the completed form to this address.
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INSTRUCTIONS FOR THE MENU SURVEY (EXPANDED)
INTRODUCTION FOR THE MENU SURVEY
Thank you for participating in the School Nutrition and Meal Cost Study-II. Without
your help, and the help of school nutrition professionals like you across the
country, this important study could not be done.
As part of this study, you are being asked to complete a Menu Survey. The objective
of the Menu Survey is to obtain a complete and accurate description of the foods
prepared and served by your school nutrition program, including foods offered in
reimbursable meals, sold a la carte, and in afterschool snacks/suppers. You will
complete the survey forms during a specified time period, referred to as the “target
week.” The target week for your school is shown on the front of the Menu Survey
Folder.
The information you provide will be combined with information from many other schools
across the country and will be used to examine the food and nutrient content of school
meals and afterschool snacks.
This Instruction Manual describes the Menu Survey and provides easy-to-follow
instructions for completing the survey forms. Along with the manual is a set of sample
completed forms that may be useful when you are completing your own survey forms.
Be sure to look over the sample completed forms.
Below, we describe the forms included in the Menu Survey Folder. The rest of this manual
explains how to complete each form.
School Nutrition Manager Survey
We have included a survey that asks about school’s food service operations (white
paper). You can complete this survey on any day you would like, and can even complete
it prior to the target week.
Daily Meal Counts Form
This one-page form (blue paper) is located behind the first tab inside the Menu Survey
Folder. This is a very simple form. All you have to do is write in the number of reimbursable
NSLP lunches and SBP breakfasts you served each day of the target week, by
reimbursement category. At the bottom of the form, you will write in your nonreimbursable food sales each day of the week or as a total across the week, by venue (if
applicable). Additional instructions are provided at the top of the form.
Reimbursable Foods Forms for Lunch and Breakfast
You will fill out these forms each day of the target week. They are located in colored
folders in the Menu Survey Folder labeled by day of the week (Monday forms, Tuesday
forms, etc.). There are separate forms for breakfast (yellow paper) and lunch (white
paper). You will use these forms to provide information about all foods and beverages
offered in reimbursable meals, including portion sizes; the number of portions prepared,
served in reimbursable meals, sold a la carte or to adults, left over, and wasted; and the
food descriptions needed for an accurate nutrient analysis. You will also indicate whether
an item was a USDA Food or prepared from a recipe.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
Recipe Forms
A booklet of Recipe Forms (grey paper) is located behind the “Recipes” tab in the Menu
Survey Folder. You will use the Recipe Forms to provide information on foods made from
scratch or by combining two or more foods or ingredients during the target week.
Alternatively, you can provide printed copies of recipes instead of completing these forms.
Self-Serve/Made-to-Order Bar Form
Behind the next tab in the Menu Survey Folder is another booklet of forms (lavender
paper) for you to use to provide information about “self-serve” bars, such as salad bars
and condiment bars, as well as made-to-order bars such as deli bars. If your school offers
self-serve or made-to-order bars, you will use a Self-Serve/Made-to-Order Bar form to
describe the foods offered on each bar.
NSLP Afterschool Snack Form
If your school provides reimbursable snacks through the NSLP to one or more afterschool
programs, you will fill out the NSLP Afterschool Snack Form (green paper). You will
complete one form for each day that afterschool snacks are offered. These forms are
similar to but much simpler than the Reimbursable Foods Form.
CACFP Afterschool Snack and Supper Form
If your school provides reimbursable snacks or suppers through the Child and Adult Care
Food Program (CACFP) to one or more afterschool programs, you will fill out the CACFP
Afterschool Snack and Supper Form (green paper) to provide information about the items
provided in afterschool snacks and/or suppers each day. This includes much of the same
information you will be providing on the Reimbursable Foods Forms.
A La Carte Foods Checklist
The A La Carte Foods Checklist is a multiple-page form (pink paper) that you will use to
identify all foods and beverages sold on an a la carte basis in your school. You only need
to fill out this form for ONE DAY OF THE WEEK. The day of the week that has been
randomly selected to be your “a la carte checklist day” is shown on the front cover of the
form.
Non-Reimbursable Foods
If your food service department sells non-reimbursable foods—that is, foods that are sold
solely on a non-reimbursable or a la carte basis and not offered as part of reimbursable
meals or snacks—you will complete either the Non-Reimbursable Foods Form or the
Non-Reimbursable Foods Inventory. These forms are only for non-reimbursable food
items sold in venues that are operated or stocked by the food service department.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
Non-Reimbursable Foods Form
You will use the Non-Reimbursable Foods Form (orange paper) to record counts of each
non-reimbursable item sold—either each day or as a total for the target week. You may
use your daily or weekly sales report, if available, to help you fill out this form.
Non-Reimbursable Foods Inventory
If you are not able to report daily or weekly counts of non-reimbursable items sold, you
may use the Non-Reimbursable Foods Inventory (orange paper) to provide information
about non-reimbursable foods. You will use this form to record, for each non-reimbursable
food item, the starting inventory on Monday of the target week, any deliveries received
during the week, and then the ending inventory on Friday.
The Rest of This Manual
The rest of this manual includes step-by-step instructions for completing each of the Menu
Survey forms. For each form, a completed sample form is provided. Please take the time
to review the instructions and all of the sample completed forms before beginning the
Menu Survey.
If You Need Assistance
We will be calling you before the start of the target week and again during the target week
to answer any questions you may have. If you have questions or need assistance at any
other time before, during, or after the target week, feel free to call or email our technical
assistants at [TA help line] or [TA email address]. Thank you for your assistance with
this important study!
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
General Guidelines for
Completing the Menu Survey
Getting Started
Please read this manual carefully. Be sure to review the sample completed forms that are
provided.
Off-Site Kitchens
If your school receives prepared meals or any components of reimbursable meals from
another school, a central kitchen, or an outside vendor during the target week, we ask
that you obtain food descriptions, product information, and recipes for these foods, as
needed. You may wish to discuss strategies for this task with your school food authority
(SFA) director.
If your schools sends prepared meals or foods (either for reimbursable meals or snacks
or non-reimbursable foods), you will be asked to provide information on the foods that are
sent off-site.
Filling Out Forms
Use pencil on all forms.
Write clearly and legibly (especially when recording numbers).
Write the name of your school and the date (if applicable) at the top of each form.
Double-check your work at the end of each day to be sure you have provided all
the necessary information.
At the End of the Week
When you have completed all forms included in the Menu Survey, please double-check
your work to make sure you have provided all the necessary information. Please place
the completed forms in the empty plastic envelope at the back of the Menu Survey Folder.
Remember to also include your completed School Nutrition Manager Survey. Return all
completed survey materials to Mathematica in the pre-addressed envelope
provided.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
Instructions for Completing the
Reimbursable Foods Forms
Purpose:
To describe foods and beverages that are offered as part of USDA
reimbursable lunches and breakfasts during the target week, and to provide
information on the number of portions of each item prepared, served in
reimbursable meals, sold a la carte, left over, and wasted (and sent off-site,
if applicable).
Location:
The Reimbursable Foods Forms are located in the five colored folders
labeled Monday-Friday, in the Menu Survey Folder. Separate forms are
provided for breakfast (yellow) and lunch (white).
Notes:
•
If your school offers reimbursable fruits and vegetables through the Fresh
Fruit and Vegetable Program during the target week, do NOT include these
fruits and vegetables on the Reimbursable Foods Form unless they are offered as
part of reimbursable lunches and breakfasts. If that is the case, be sure to report
only the portions that were prepared and served as part of reimbursable meals.
•
If your school offers meals to pre-kindergarten students, do NOT include any
foods that are offered only to these students and do NOT include the meals offered
to these students when reporting the number of reimbursable meals planned and
served each day.
•
Be sure to look at the sample completed Reimbursable Foods Forms that are
provided. Looking at the sample forms as you read the instructions will make it
easier to understand what you need to do when filling out the forms.
How to Complete the Reimbursable Foods Form
Reimbursable Meal Counts
On the top right-hand corner of the form, you will see the Reimbursable Meal Counts
box. The questions in this box ask about the number of reimbursable meals (breakfast or
lunch) you planned to serve for the day and the number of reimbursable meals that you
actually served that day. Record the answers to both questions in the spaces provided.
Your production records may include this information. If not, you may need to talk to your
SFA director to obtain it.
Column A: Food Item
You will use this column to identify foods and beverages offered in reimbursable meals
each day. Most foods are already listed for you. Others you will need to write in. In thinking
about all the foods offered in your cafeteria each day and deciding which ones to include
on this form, keep the following in mind:
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
DO INCLUDE:
•
All foods and beverages offered in reimbursable meals (even if they may not count
toward USDA meal pattern requirements).
•
All condiments, salad dressings, optional toppings, desserts, and snack items.
DO NOT INCLUDE:
•
Foods and beverages that are offered only a la carte or only to adults. (Instead,
record these food and beverages on the Non-Reimbursable Foods Form or NonReimbursable Foods Inventory.)
•
Foods and beverages that are offered and served only to pre-kindergarten
students.
•
Foods and beverages that were planned for a given day, but not actually prepared
at your school because a substitution was made.
When foods are paired or offered together:
When a bread/grain, meat/meat alternate, fruit, or vegetable offering is paired with, or
offered only with another menu item, add a note in Column A to make this clear.
Examples:
For crackers that are offered only with a Chef’s salad, add a note…
Crackers w/ Chef’s salad
For toast that is offered only with cereal, add a note…
Toast w/ cereal
For a cheese stick that is offered only with a peanut butter
sandwich, add a note…
Cheese stick w/ peanut butter sandwich
For blueberries that are offered only with pancakes, add a note…
Blueberries w/ pancakes
When writing in foods that are not already listed on the form:
•
Record foods in their appropriate food group sections whenever possible. Blank
lines are provided at the end of each section for your entries. A generous amount of
additional space is provided at the end of the form for recording items that do not fit
in the individual food group sections (for example, not enough blank lines for
additional fruits), as well as items that belong in a food group that is not listed on the
form.
•
Salad bars, condiment bars, and other food bars, whether self-serve or made-toorder, should be listed as single menu items. Salad bars (both side salad bars and
entrée salad bars) and other common theme bars are prelisted. Use separate lines
for any self-serve bars that are not prelisted.
•
If your school offers bag or box meals or fully preplated meals, write each type of
meal on a separate line. Complete a Recipe Form for each type of meal to identify
all of the foods and beverages included in the meal.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
If your school offers different foods to students in different grade groups:
Record each food offered separately and add a note in Column A to make it clear
which foods are offered to each grade group.
•
Example:
If your schools serves students in grades 6-8 and 9-12 and different entrées
are offered to each grade groups, you would indicate this by listing each food
separately and adding a note next to each food, as shown below.
A.
Food Item
Taco for grades 6-8
Burrito for grades 9-12
Column B: Portion Size
For each item offered in reimbursable meals, write the size of one individual serving, as
offered to students.
•
Include both the amount and the unit of measure (if not already printed on the
form). For example:
Food Item
Amount
Unit
Broccoli
¾
cup
Chicken patty
2.5
oz.
Tossed salad
½
cup
You may change the printed unit for any food if your school serves the item in a
different unit of measure.
•
Include the weight (oz.) of one portion whenever available, especially for
commercially prepared foods, such as burritos, chicken or fish nuggets, pizza,
doughnuts, or cookies.
•
For foods that are offered self-serve, write “self-serve” as the portion size.
•
If your school offers different portion sizes of the same food, for example to
students in two different grade groups, you will need to list the food twice (on two
separate lines) and write in the different portion sizes.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
Example:
If your school serves students in grades 6-8 and 9-12 and you offer different
portion sizes for canned peaches, you would indicate this by listing the food
twice and adding a note about which portion size applies to which grade group,
as shown below.
A.
B.
Portion Size
(Include
Units)
Food Item
Peaches, canned for grades 6-8
½ cup
Peaches, canned for grades 9-12
1 cup
Column C: Number of Portions
In the sub-columns under Column C, for each menu item, you will enter the total number
of portions prepared, and the number of portions sent off-site (if applicable), served to
students in reimbursable meals, served a la carte or to adults/others, left over and saved
for later use, and wasted. Note that the number of portions entered in the last five subcolumns (Sent Off-Site, Reimbursable Served, Served a La Carte or to Adults/Others,
Left Over for Later Use, and Wasted) should add up to the total number of portions
prepared (Total Prepared).
Total Portions Prepared
For each menu item, enter the total number of portions prepared. Include portions that
are prepared for reimbursable meals at your school as well as portions that are prepared
to be sent off-site, served a la carte and to adults or others. For pre-packaged foods and
beverages, the total number of portions prepared refers to the number of individual
packages that are put out in the serving area. For example for cartons of juice, write the
number of cartons that are placed on the serving line before and throughout the meal
period.
Portions Sent Off-Site (if applicable)
If your school prepares food to be served at other schools or facilities, enter the total
number of portions for each item that is sent off-site. Include portions sent off-site on the
day they are sent – it doesn’t matter if they will be served on the same day or another
day. If your school does not prepare food to be served at other schools or facilities, you
do not need to complete this column.
Reimbursable Portions Served
For each menu item, enter the number of reimbursable portions served to students at
your school (excluding portions sold a la carte or to adults/others). Your production
records may include this information; if not, you may need to talk to your SFA director
about putting a procedure in place to record it for the target week. If a menu item is
prepared and available to students but none are served in reimbursable meals, be sure
to enter a zero in the Reimbursable Served column.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
Portions Served A La Carte or to Adults/Others
Also for each menu item, enter the number of portions that are served a la carte, to adults,
or to others who are not receiving meals through the NSLP or SBP. If no portions are
served a la carte or to adults, enter zero in this column.
Portions Left Over for Later Use
At the end of each meal, enter the number of portions that were not served on this day,
but were leftover and may be served on a different day. For instance, this may include
cartons of milk or juice to be used on the following day. Do not include leftover portions
that are thrown away. If no portions are left over and saved for later use, enter zero in this
column.
Portions Wasted
Also enter the number of portions that were not served and must be thrown out because
they cannot be used on a different day. For instance, this may include food prepared in a
large dish, such as macaroni and cheese. If no portions are wasted, enter zero in this
column.
Example:
Note that for each of the following menu items, the number of portions entered in
the last five sub-columns (Sent Off-Site, Reimbursable Served, Served a La Carte
or to Adults/Others, Left Over, and Wasted) add up to the total number of portions
prepared (Total Prepared).
A.
B.
C.
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Offsite
Orange juice
8 fl. oz.
140
1 cup
200
Macaroni and cheese
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
0
120
10
10
0
20
160
0
0
20
Column D: Manufacturer/Brand Name and Product Code
This column is used to provide information on the manufacturer, brand name, and product
code of certain foods listed in Column A. We have shaded this column for pre-listed foods
that do not require manufacturer/brand name, or a product code.
•
For all other commercially prepared food products you serve, including entrees,
meat/meat alternates, and most bread/grain items (including biscuits, doughnuts,
breakfast pastries, and pancakes), please fill in the manufacturer/brand and
product code information in Column D.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
•
Please do your best to record whatever manufacturer and/or brand information is
available (or at least how the food is described on the package label) for all
required foods. Always include a product code, if available. The product code is
usually located on the label of the box in which commercially prepared food
products are delivered. An example is shown below.
•
Below are additional examples of manufacturer and brand names, and products
codes, for some foods.
Food Item
(Column A)
Manufacturer/Brand Name
and Product Code (Column D)
Pizza, pepperoni
Super Donut
Pancake-on-a-stick
Schwan’s/Tony’s 78546
Super Bakery 6001
State Fair 70481
•
If your school purchases commercially prepared food products, including ones that
are lower in fat or sodium or include whole grains, you may wish to include package
labels to tell us more about the products. This will help ensure that the nutrient
analysis is accurate and reflects the types of foods used in your school meal
program.
•
If you decide that you would like to give us package labels, you can put them in
the envelope with the completed forms at the end of the week.
Column E: Food Description
This column is used to describe foods so that an accurate nutrient analysis can be done.
For most of the pre-listed items, you will need to check a box or write in a response. For
example, for some foods you will be asked to check whether a food is regular, low-fat or
fat-free, or if it is breaded or has icing. For some foods you will be asked to specify the
type or variety of the food, such as the type of bread (100% whole wheat, rye bread, etc.),
or the flavor of milk or yogurt.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
It is especially important to complete this column for commercially prepared products and
items that you add to the form. Please provide as complete a description of the item as
possible. Depending on the item, this may include information on:
type (100% whole wheat bread, rye bread, blueberry muffin, unbreaded chicken
patty, low-sodium green beans)
form (fresh, frozen or canned vegetable or fruit)
flavor (Strawberry milk, oatmeal cookie, vanilla yogurt)
fat content (low-fat yogurt, reduced-fat sour cream, fat-free salad dressing)
Column F: Check Box if USDA Food
For food items in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column F.
Column G: Check Box if Prepared from a Recipe
For foods in Column A that are prepared from a recipe—that is, foods that are made from
scratch or by combining two or more foods or ingredients—place a check mark in Column
G. Use these checkmarks to remind you to complete a Recipe Form or provide a printed
recipe.
We have shaded this column for pre-listed foods that do not require recipes. If the column
is not shaded, you may need a recipe, depending on the food. For example, for purchased
pizza that is served as is, a recipe is not needed. For pizza that is prepared from scratch
or is a modified version of a purchased product (for example, you added your own
toppings), a recipe is needed.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
Instructions for Completing the
Recipe Forms
Purpose:
To describe the types and amounts of ingredients used in preparing foods
made from scratch or made by combining two or more foods or ingredients.
Location:
A booklet of Recipe Forms (grey) is located behind the “Recipes” tab in the
Menu Survey Folder. If you need more forms than are included in the
booklet, make copies of the form and file the completed extra forms inside
the Recipe Form booklet.
Notes:
•
You may not have to fill out the Recipe Form if a printed copy of the recipe
is available. See the special instructions later in this section (page 14).
•
A recipe is needed for every item that is prepared from scratch or prepared
by combining two or more foods or ingredients. This includes all sandwiches
and foods prepared or cooked with added butter, margarine, dressings, or other
condiments.
•
Some foods may need more than one Recipe Form. For example, for a tuna
salad sandwich, you will need to use two Recipe Forms—one for the tuna salad
mixture and one for the assembled tuna salad sandwich. The same is true for a
brownie or cake with icing. See the sample completed Recipe Forms for an
example of a situation where two Recipe Forms are needed.
•
If the same recipe was prepared more than once during the target week, you
only need to fill out a Recipe Form once and be sure to check the boxes at the top
of the form to indicate which days of the week the recipe was served, unless the
recipe is prepared differently on other days of the week. If variations of a recipe
are used on different days, a separate Recipe Form is needed for each variation.
•
Be sure to look at the sample completed Recipe Forms that are provided.
Looking at these forms as you read the instructions will make it easier to
understand what you need to do when filling out the form.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
How to Complete the Recipe Forms
Recipe/Food Name
Write the complete name of the recipe or food on the line provided in the upper right
hand corner of the form. Please be sure that the name is clear enough that we will be
able to match it up with the appropriate item on the Reimbursable Foods Form.
For recipes that are used in other recipe items, mention both recipes in the name. For
example, “Tuna salad for tuna sandwich.”
Meal
Check the meal or meals in which the recipe/food item was offered.
Day
Check the day or days of the target week on which the recipe/food was offered. Check
“all” if the item is offered every day.
Size of One Serving
Write the size of one individual serving, as offered to students. Include both the amount
and unit of measure (Examples: 1/4 cup, 8 fluid ounces, 1 sandwich).
Number of Servings Prepared
Please record the total number of individual servings prepared (recipe yield) in the
space provided. For some items, such as sandwiches, the Recipe Form describes the
ingredients or components of a single serving (Examples: 1 sandwich, 1 Chef’s salad).
Column A: Ingredient Name
List all foods and ingredients used to prepare the recipe/food. Remember to include all
items used in food preparation, including seasonings and salt, as well as oils, butter,
margarine, and other fats used in cooking.
Column B: Amount in Recipe
For each item listed in Column A, write the amount used in Column B. Be sure to include
information on both the amount and the unit of measure (Examples: 2 Tbsp, 6 oz, 5
cups, 7.5 gallons, 35 lbs).
Be sure to provide amount information on the form of the ingredient when it was
measured. For example, was pasta or rice measured cooked or uncooked? Was meat
measured raw or after cooking? Was the cheese sliced, cubed, shredded, or grated?
Column C: Manufacturer/Brand Name and Product Code
If the ingredient or food listed in Column A is a commercially prepared food, list the
manufacturer and/or brand name as well as the product code.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
Column D: Ingredient Description
For each item listed in Column A, use this column to provide details about the food or
ingredient that will allow us to do an accurate nutrient analysis. Depending on the item,
this may include information on:
type (whole wheat flour, brown rice, ground turkey, low-sodium tomato sauce)
form (fresh, frozen or canned vegetables, fruits, or meats)
cooking status (cooked, uncooked, dry, raw)
fat content (part-skim cheese, 1% fat milk, fat-free mayonnaise)
whether whole grain-rich
See the sample completed forms for examples of ingredient descriptions.
Column E: Check Box if USDA Food
For ingredients in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column E.
Column F: Check Box if Prepared from a Recipe
For ingredients in Column A that require a recipe, place a check mark in the appropriate
box in Column F. Use these checkmarks to remind you to complete an additional Recipe
Form.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
If You Can Provide a Printed Copy of the Recipe…
Be sure to:
•
Staple or clip a copy of the printed recipe to a blank Recipe Form in the booklet,
and indicate on the Recipe Form the meal and days the recipe was used.
•
Mark the recipe, as needed, to show how the recipe was prepared in your school,
and make sure the name of the recipe matches the name used on the
Reimbursable Foods Form.
Make sure the recipe includes:
•
Yield information: size of one serving and number of servings prepared.
•
A complete description of all ingredients, including manufacturer and/or brand and
product code for commercially prepared food products.
•
An indication of any ingredients that are USDA Foods, for example, write “USDA”
beside the ingredient name.
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INSTRUCTIONS FOR EXPANDED MENU SURVEY
Instructions for Completing the Self-Serve/
Made-to-Order Bar Forms
Purpose:
To describe the ingredients included on self-serve bars such as salad bars,
theme bars, and condiment bars; made-to-order bars such as deli bars.
Location:
A booklet of Self-Serve/Made-to-Order Bar Forms (lavender) is located
behind the “Self-Serve Bars” tab in the Menu Survey Folder.
Notes:
•
A separate Self-Serve/Made-to-Order Bar Forms must be completed for each type
of self-serve bar or made-to-order bar offered. If the same bar was offered more
than once during the target week, you only need to fill out one Self-Serve/Madeto-Order Bar Forms and indicate the days on which the bar was offered. If the
foods/ingredients offered on the bar differ on other days of the week, a
separate form is needed for each day they are different.
•
Be sure to look at the sample completed Self-Serve/Made-to-Order Bar
Forms that are provided. Looking at these forms as you read the instructions will
make it easier to understand what you need to do when filling out the form.
How to Complete the Self-Serve/Made-to-Order Bar Forms
Name of Bar
Write the complete name of the self-serve/made-to-order bar on the line provided in the
upper right hand corner of the form. Please be sure that the name is clear enough that
we will be able to match it up with the same item on the Reimbursable Foods Form.
Meal
Check the meal or meals in which the bar was offered during the target week.
Day
Check the day or days of the target week on which the bar was offered. Check “all” if the
bar (with all the same ingredients) is offered every day.
Column A: Food Name
List all foods and ingredients offered on the bar. If you need additional lines, write the
name of the bar and “continued” on a blank Self-Serve/Made-to-Order Bar Form and list
remaining foods/ingredients.
15
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Column B: Portion Size (if pre-portioned)
For pre-portioned items only, describe the size of one portion. This includes items such
as baked potatoes, tortillas, packaged crackers, boxes of raisins, or packages of
sunflower seeds. It also includes items that might be portioned out by cafeteria servers,
such as pasta on a pasta bar, cold cuts on a deli bar, or meat and cheese items on a
salad bar.
Be sure to include information on both the amount and the unit of measure for preportioned items. See the sample completed Self-Serve/Made-to-Order Bar Forms for
examples.
Column C: Manufacturer/Brand Name and Product
For commercially prepared food products, please record the manufacturer and/or brand
name and a product code in Column C.
Column D: Food Description
For each item listed in Column A, use this column to provide details about the food or
ingredient that will allow us to do an accurate nutrient analysis. Depending on the item,
this may include information on:
type (100% whole grain bread, rye bread, graham cracker, cheddar cheese,
low-sodium green beans, deli turkey)
form (fresh, frozen or canned vegetables or fruit)
cooking status (cooked, uncooked, dry, raw)
fat content (low-fat yogurt, reduced-fat sour cream, fat-free salad dressing)
whether whole grain-rich
See the sample completed forms for examples of ingredient descriptions.
Column E: Check Box if USDA Food
For foods in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column E.
Column F: Check Box if Prepared from a Recipe
For foods in Column A that require a recipe, place a check mark in the appropriate box
in Column F. Use these checkmarks to remind you to complete a Recipe Form.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
16
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Instructions for Completing the
NSLP Afterschool Snack Form
Purpose:
To describe the foods and beverages offered in NSLP reimbursable
afterschool snacks during the target week, and to provide information on
the number of individual snack items prepared and served, as well as the
total number of reimbursable snacks served to students.
Location:
A booklet of NSLP Afterschool Snack Forms (green paper) is behind the
“NSLP Afterschool Snacks” tab in the Menu Survey Folder.
Notes:
•
Only include afterschool snacks offered through the National School
Lunch Program (NSLP). If your school offers snacks and/or suppers through
the Child and Adult Care Food Program (CACFP), you will complete the
CACFP Afterschool Snack and Supper Form.
•
If your school offers reimbursable fruits and vegetables through the
Fresh Fruit and Vegetable Program during the target week, do NOT include
these fruits and vegetables on the NSLP Afterschool Snack Form unless they
are offered as part of reimbursable afterschool snacks. If that is the case, be
sure to report only the portions that were prepared and served as part of
reimbursable afterschool snacks.
•
Be sure to look at the sample completed NSLP Afterschool Snack Form
that is provided. Looking at this sample as you read the instructions will make
it easier to understand what you need to do when filling out the form.
How to Complete the NSLP Afterschool Snack Form
On the front page of this booklet answer question 1 by indicating the days during the
target week that NSLP afterschool snacks were offered. Complete one NSLP Afterschool
Snack Form for each day snacks were offered.
This form is similar to the Reimbursable Foods Form. It includes columns for the food
item, portion sizes, the number of portions prepared/available and served, and the food
descriptions needed for an accurate nutrient analysis. You will also check if any item was
a USDA Food or prepared from a recipe. Depending on how your afterschool program
operates, you may need assistance from afterschool program staff to complete the
columns for number of portions served.
Day
Check the day of the target week for which this form is being completed.
17
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Number of Reimbursable Snacks Served Onsite
At the top of the form, record the total number of reimbursable snacks served to students
at your school that day.
Column A: Food Item
You will use this column to identify foods and beverages offered in reimbursable NSLP
afterschool snacks each day. Some foods are already listed for you. Others you will
need to write in. In thinking about all the foods offered in your NSLP afterschool snacks
each day and deciding which to include on this form, keep the following in mind:
DO INCLUDE:
•
All foods and beverages offered in NSLP afterschool snacks (even if they may
not count toward USDA meal pattern requirements).
DO NOT INCLUDE:
•
Foods and beverages that are offered only to adults.
•
Foods and beverages that were planned for a given day, but not actually
prepared/available that day.
When writing in foods that are not already listed on the form:
•
Record foods in appropriate food group sections. Blank lines are provided at the
end of each section for your entries.
Column B: Portion Size
For each item offered in NSLP afterschool snacks, write the size of one individual serving,
as offered to students. If the snack item is pre-packaged, list the actual package size or
weight, not “1 package.”
•
Include both the amount and the unit of measure:
Food Item
•
Amount
Unit
Banana, fresh
1
Medium
Orange juice
6
fl. oz.
Granola bar
1.5
oz.
If a food or beverage is offered in more than one portion size (for different grade
groups), list the food or beverage on separate lines and write in the different portion
sizes.
18
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Example:
A.
B.
C.
Number of Portions
Onsite
Portion
Size
(Include
Units)
Sent
Off-Site
Reimbursable
Prepared/
Available
Reimbursable
Served
Orange juice
6 fl. oz.
0
50
25
Orange juice
8 fl. oz.
0
50
50
Food Item
Column C: Number of Portions
Sent Off-Site (if applicable)
If your school prepares foods to be served in NSLP afterschool snacks at other schools
or facilities, enter the number of portions of each snack item that are sent off-site.
Number of Reimbursable Portions Prepared/Available
For each snack item, write in the number of reimbursable portions prepared or available
to be served at your school. The number of reimbursable portions prepared/available
should reflect the actual number of servings available for students to select as part of a
reimbursable NSLP afterschool snack.
Number of Reimbursable Portions Served
Also for each snack item, enter the number of reimbursable portions or individual items
served to (or selected by) students as part of a reimbursable NSLP afterschool snack,
excluding portions served to adults. If a menu item is prepared and available to students
but no portions are served, be sure to enter a zero in this column.
You may need to ask the afterschool program staff for this information. You can also give
the afterschool program staff a copy of the NSLP Afterschool Snack Form and ask them
to complete this column.
Column D: Manufacturer/Brand Name and Product Code
This column is used to provide information on the manufacturer, brand name, and product
code of certain foods listed in Column A. We have shaded this column for pre-listed foods
that do not require manufacturer/brand name or a product code. For all other
commercially prepared food products you serve, please fill in the manufacturer/brand and
product code information in Column D.
19
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Column E: Food Description
This column is used to describe foods so that an accurate nutrient analysis can be done.
For most of the pre-listed items, you will need to check a box or write in a response. For
example, for some foods you will be asked to check whether a food is regular, low-fat or
fat-free, or if it is whole grain-rich or reduced-fat. For some foods you will be asked to
specify the type or variety of the food, such as the type of crackers (graham, wheat,
saltines, etc.), or the flavor of milk or yogurt.
It is especially important to complete this column for commercially prepared products and
items that you add to the form. Please provide as complete a description of the item as
possible. Depending on the item, this may include information on:
type (1% milk; 100% whole wheat bread; blueberry muffin)
form (fresh, frozen or canned vegetable or fruit)
flavor (chocolate milk, strawberry yogurt)
fat content (low-fat yogurt, or fat-free salad dressing)
Column F: Check Box if USDA Food
For food items in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column F.
Column G: Check Box if Prepared from a Recipe
For foods in Column A that require a recipe, place a check mark in the appropriate box in
Column G. Use these checkmarks to remind you to complete a Recipe Form or provide
a printed recipe.
We have shaded this column for pre-listed foods that do not require recipes. If the column
is not shaded, you may need a recipe, depending on the food. For example, for purchased
pizza that is served as is, a recipe is not needed. For pizza that is prepared from scratch
or is a modified version of a purchased product (for example, you added your own
toppings), a recipe is needed.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
20
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Instructions for Completing the
CACFP Afterschool Snack and Supper Form
Purpose:
To describe the foods and beverages offered in CACFP reimbursable
afterschool snacks and suppers during the target week, and to provide
information on the number of individual snack/supper items prepared and
served, as well as the total number of reimbursable snacks/suppers served
to students.
Location:
A booklet of CACFP Afterschool Snack and Supper Forms (green paper) is
behind the “CACFP Afterschool Snacks/Suppers” tab in the Menu Survey
Folder.
Notes:
•
Only include afterschool snacks and suppers offered through the Child
and Adult Care Food Program (CACFP). If your school offers afterschool
snacks through the National School Lunch Program (NSLP), you will complete
the NSLP Afterschool Snack Form.
•
If your school offers reimbursable fruits and vegetables through the
Fresh Fruit and Vegetable Program during the target week, do NOT include
these fruits and vegetables on the CACFP Afterschool Snack and Supper Form
unless they are offered as part of reimbursable afterschool snacks or suppers.
If that is the case, be sure to report only the portions that were prepared and
served as part of reimbursable afterschool snacks or suppers.
•
Be sure to look at the sample completed CACFP Afterschool Snack and
Supper Form that is provided. Looking at this sample as you read the
instructions will make it easier to understand what you need to do when filling
out the form.
How to Complete the CACFP Afterschool Snack and Supper Form
On the front page of this booklet answer question 1 by indicating the days during the
target week that CACFP afterschool snacks and/or suppers were offered. Complete one
CACFP Afterschool Snack and Supper Form for each day afterschool snacks and/or
suppers were offered.
This form is similar to the Reimbursable Foods Form. It includes columns for the food
item, portion sizes, the number of portions prepared/available and served, and the food
descriptions needed for an accurate nutrient analysis. You will also check if any item was
a USDA Food or prepared from a recipe. Depending on how your afterschool program
operates, you may need assistance from afterschool program staff to complete the
columns for number of portions served.
21
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Day
Check the day of the target week for which this form is being completed.
Number of Reimbursable Snacks and/or Suppers Served Onsite
At the top of the form record the total number of CACFP reimbursable snacks and/or
suppers served to students at your school that day.
Column A: Food Item
You will use this column to identify foods and beverages offered in CACFP afterschool
snacks and/or suppers each day. Some foods are already listed for you. Others you will
need to write in. In thinking about all the foods offered in your snacks each day and
deciding which to include on this form, keep the following in mind:
DO INCLUDE:
•
All foods and beverages offered in CACFP reimbursable afterschool snacks
and/or suppers (even if they may not count toward USDA meal pattern
requirements).
DO NOT INCLUDE:
•
Foods and beverages that are offered only to adults.
•
Foods and beverages that were planned for a given day, but not actually
prepared/available that day.
When writing in foods that are not already listed on the form:
•
Record foods in their appropriate food group sections whenever possible. Blank
lines are provided at the end of each section for your entries. A generous amount
of additional space is provided at the end of the form for recording items that do
not fit in the individual food group sections (for example, not enough blank lines
for additional fruits), as well as items that belong in a food group that is not listed
on the form.
Column B: Portion Size
For each item offered in CACFP afterschool snacks or suppers, write the size of one
individual serving, as offered to students. If the snack/supper item is pre-packaged, list
the actual package size or weight, not “1 package.”
•
Include both the amount and the unit of measure:
Food Item
Amount
Unit
Banana, fresh
1
medium
Orange juice
6
fl. oz.
Granola bar
1.5
oz.
22
INSTRUCTIONS FOR EXPANDED MENU SURVEY
•
If a food or beverage is offered in more than one portion size (for different grade
groups), list the food or beverage on separate lines and write in the different portion
sizes.
Example:
A.
B.
C.
Number of Portions
Onsite
Portion
Size
(Include
Units)
Sent
Off-Site
Reimbursable
Prepared/
Available
Reimbursable
Served
Orange juice
6 fl. oz.
0
50
25
Orange juice
8 fl. oz.
0
50
50
Food Item
Column C: Number of Portions
Sent Off-Site (if applicable)
If your schools prepares foods to be served in CACFP snacks/suppers at other schools
or facilities, enter the number of portions of each item that are sent off-site.
Number of Reimbursable Portions Prepared/Available
For each snack/supper item offered, write in the number of reimbursable portions
prepared or available. The number of reimbursable portions prepared should reflect the
actual number of servings available for students at your school to select as part of a
CACFP snack or supper. If an item is prepared/available for both a snack and supper,
write the combined total.
Number of Reimbursable Portions Served
Also for each snack item, enter the number of reimbursable portions or individual items
served to (or selected by) students as part of a CACFP snack or supper, excluding
portions served to adults. If a menu item is prepared and available to students but no
portions are served, be sure to enter a zero in this column. If an item is served during
both a snack and supper, write the combined total.
You may need to ask the afterschool program staff for this information. You can also give
the afterschool program staff a copy of the CACFP Afterschool Snack and Supper Form
and ask them to complete this column.
Column D: Manufacturer/Brand Name and Product Code
This column is used to provide information on the manufacturer, brand name, and product
code of certain foods listed in Column A. We have shaded this column for pre-listed foods
that do not require manufacturer/brand name, or a product code. For all other
commercially prepared food products you serve, please fill in the manufacturer/brand and
product code information in Column D.
23
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Column E: Food Description
This column is used to describe foods so that an accurate nutrient analysis can be done.
For most of the pre-listed items, you will need to check a box or write in a response. For
example, for some foods you will be asked to check whether a food is regular, low-fat or
fat-free, or if it is whole grain-rich or reduced-fat. For some foods you will be asked to
specify the type or variety of the food, such as the type of crackers (graham, wheat,
saltines, etc.), or the flavor of milk or yogurt.
It is especially important to complete this column for commercially prepared products and
items that you add to the form. Please provide as complete a description of the item as
possible. Depending on the item, this may include information on:
type (1% milk; 100% whole wheat bread; blueberry muffin)
form (fresh, frozen or canned vegetable or fruit)
flavor (chocolate milk, strawberry yogurt)
fat content (low-fat yogurt, or fat-free salad dressing)
Column F: Check Box if USDA Food
For food items in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column F.
Column G: Check Box if Prepared from a Recipe
For foods in Column A that require a recipe, place a check mark in the appropriate box in
Column G. Use these checkmarks to remind you to complete a Recipe Form or provide
a printed recipe.
We have shaded this column for pre-listed foods that do not require recipes. If the column
is not shaded, you may need a recipe, depending on the food. For example, for purchased
pizza that is served as is, a recipe is not needed. For pizza that is prepared from scratch
or is a modified version of a purchased product (for example, you added your own
toppings), a recipe is needed.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
24
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Instructions for Completing the
A La Carte Foods Checklist
Purpose:
To identify foods and beverages your school offers on an a la carte basis at
lunch and breakfast.
Location:
The A La Carte Foods Checklist (pink paper) is located behind the
“A La Carte” tab in the Menu Survey Folder.
Notes:
•
Complete the A La Carte Foods Checklist on the one day of the target week
specified on the front of the Menu Survey Folder. Be sure to complete the
checklist even if your school sells only milk on an a la carte basis.
•
Be sure to look at the sample completed A La Carte Foods Checklist that is
provided. Looking at this sample as you read the instructions will make it easier
to understand what you need to do when filling out the form.
How to Complete the A La Carte Foods Checklist
1. Write the name of your school and the date on the first page of the form.
2. Place a check mark in the box next to each food and beverage that was available
for a la carte purchase on the specified day. This includes items that are sold only
a la carte as well as components of a reimbursable meal that may be purchased a
la carte. There are separate check boxes for lunch and breakfast.
3. If a food or beverage is usually or sometimes available a la carte, but was not
available on the specified day, do not check the box.
4. If your school had a la carte foods or beverages available on your specified day
that are not included in the checklist, please write in the names of these foods and
beverages under the appropriate category. Extra lines are also available on the
last page of the checklist, if necessary. Be sure to indicate whether each food or
beverage was offered at breakfast and/or lunch.
25
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Instructions for Completing the
Non-Reimbursable Foods Form
Purpose:
To describe foods that are sold only on a non-reimbursable or a la carte
basis and to provide information on the number of portions of each item
sold—either each day of the target week or as a total across the week.
Notes:
•
Non-reimbursable foods are not offered as part of reimbursable meals or snacks.
•
Include only non-reimbursable foods from venues that are operated or
stocked by the food service department, including foods sold on an a la carteonly basis in cafeteria serving lines, in vending machines, snack bars, school
stores, and food carts.
•
You will use one Non-Reimbursable Foods Form for the whole week.
•
You may use your daily or weekly sales report, if available, to help you fill out this
form.
•
Be sure to look at the sample completed Non-Reimbursable Foods Form that
is provided. Looking at this sample as you read the instructions will make it easier
to understand what you need to do when filling out the form.
How to Complete the Non-Reimbursable Foods Form
Meal
At the top of the form, check the appropriate box or boxes to indicate when any nonreimbursable foods are offered: during breakfast, lunch, and/or outside of meal periods.
Foods may be offered outside of meal periods, just one time, or throughout the day.
Where Offered
Non-reimbursable foods may be sold on cafeteria serving lines or in other venues, such
as vending machines, snack bars, school stores, or food carts or at another school or
facility off-site. Indicate the venues where the non-reimbursable food items listed on this
form are offered, checking all boxes that apply. If the food service department sells nonreimbursable foods in a venue that is not listed, check “Other,” and write in the name of
the venue.
26
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Column A: Food Name
At the start of the target week, use this column to list all non-reimbursable items that are
sold across all venues. Creating a list of items at the start of the week will make the
form easier to fill out.
If a food item is available in different flavors but the brand and package sizes are the
same, (for example, different flavors of 12 fl oz Gatorade®), you can list the items once.
Column B: Portion Size
For each non-reimbursable item, write the size of one individual serving, as offered.
Include both the amount and the unit of measure.
•
If any items that are pre-packaged, record the actual package size, weight, or
volume (2.5 oz or 12 fl oz), not “1 package.”
•
For items prepared from recipes, write the size of one individual serving (“1/2 cup”
vanilla pudding) or simply the number of items offered (“1 sandwich,” “2 pieces,”
or “1 each”).
•
If a food or beverage item is offered in more than one portion size, you will need
to list the item more than once, on separate lines for each portion size.
A.
B.
Food Name
Portion Size
(Include Units)
Pizza, pepperoni
5.0 oz
Pizza, pepperoni
3.5 oz
Column C: Check Box if Prepared from a Recipe
If an item was prepared from a recipe, check the box in Column C. Use these
checkmarks to remind you to complete a Recipe Form or provide a printed recipe.
Remember that recipes are needed for all items that are made by combining two or
more foods or ingredients.
Column D: Manufacturer/Brand Name and Product Code
For commercially prepared foods that are not prepared from a recipe, please record the
manufacturer/brand name and a product code (if available) in Column D. Below are
examples of manufacturer/brand names and products codes for some foods.
A.
D.
Food Name
Manufacturer/Brand Name and Product Code
Pizza, pepperoni
Schwan’s/Tony’s 78546
Super Donut
Super Bakery 6001
Pancake-on-a-stick
State Fair 70481
27
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Column E: Food Description
For each item listed in Column A, use this column to provide details about the type or
variety of the food. Please provide as complete a description of the item as possible.
Depending on the item, this may include information on:
type: such as 100% whole wheat bread, rye bread, blueberry muffin, un-breaded
chicken patty, low-sodium green beans
form: such as fresh, frozen or canned vegetable or fruit
flavor: for example strawberry milk, oatmeal cookie, vanilla yogurt; and
fat content: such as low-fat yogurt, reduced-fat sour cream, fat-free salad dressing
If a food item is available in different flavors and the brand and package sizes are the
same, group the items and list them only once with the food description “assorted flavors
or types." An example of this is Gatorade®, which comes in many flavors. You would
record this by listing the name and portion size of the item, Gatorade®, 12 oz, and
“Assorted flavors” in Column E, for the Food Description.
Column F: Daily Number of Portions
You will use the sub-columns under Column F if you can report the number of portions
of each item sold each day of the target week. Be sure to include counts from all venues
operated or stocked by the food service department.
Sent Off-Site (if applicable)
If your school sends any non-reimbursable foods to other schools or facilities, enter the
number of portions of each item that are sent off-site. Include portions sent off-site on
the day they are sent–it doesn’t matter if they will be sold on the same day or another
day.
Sold Onsite
For all non-reimbursable items, enter the total number of portions sold onsite that day.
If an item is offered but not sold, be sure to enter zero.
Left Over for Later Use
For any non-reimbursable items that require some preparation (for example, heating) or
are prepared from a recipe, enter the number of portions that were not sold and instead,
were leftover and saved for later use. For example, this may include cookies prepared
from a recipe that are wrapped in plastic wrap and may be offered the following day. For
foods sold in their original packaging, enter a zero in this column.
28
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Wasted
For any non-reimbursable items that require some preparation (for example, heating) or
are prepared from a recipe, enter the number of portions that were not sold and must be
thrown out because they cannot be served on a different day. For instance, this may
include frozen pizza that has already been removed from its package and heated. For
foods sold in their original packaging, enter a zero in this column.
And remember, if there are no portions to enter in a column, enter zero.
Column G: Weekly Total Number of Portions
If you prefer to record counts of the number of portions sold across the entire week, you
will record those weekly counts in Column G. Be sure to include counts from all venues
operated or stocked by food service.
Sent Off-Site (if applicable)
If your schools sends any non-reimbursable foods to other schools or facilities, enter the
number of portions of each item that are sent off-site.
Sold Onsite
For all non-reimbursable items, enter the total number of portions sold onsite that day.
If an item is offered but not sold, be sure to enter zero.
Left Over for Later Use
For any non-reimbursable items that require some preparation (for example, heating) or
are prepared from a recipe, enter the number of portions that were not sold and instead,
were leftover and saved for later use. For example, this may include cookies prepared
from a recipe that are wrapped in plastic wrap and may be offered the following day. For
foods sold in their original packaging, enter a zero in this column.
Wasted
For any non-reimbursable items that require some preparation (for example, heating) or
are prepared from a recipe, enter the number of portions that were not sold and must be
thrown out because they cannot be served on a different day. For instance, this may
include frozen pizza that has already been removed from its package and heated. For
foods sold in their original packaging, enter a zero in this column.
And remember, if there are no portions to enter in a column, enter zero.
29
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Instructions for Completing the
Non-Reimbursable Foods Inventory
Purpose:
To describe and record inventory information for non-reimbursable foods for
which you do not have the daily or weekly count of units sold for each food
item. You will use this form to take an inventory of the foods at the start of
the week, record the quantity of foods received during the week, and then
the inventory left at the end of the week.
Notes:
•
Non-reimbursable foods are not offered as part of reimbursable meals or snacks.
•
Include only non-reimbursable foods from venues that are operated or
stocked by the food service department, including foods sold on an a la carteonly basis in cafeteria serving lines, in vending machines, snack bars, school
stores, and food carts.
•
The goal of this form is to provide information about the weekly INVENTORY and
should only be used if you do not have daily or weekly counts of the number of
portions sold. If you have daily or weekly counts, complete the Non-Reimbursable
Foods Form instead.
•
You will use one Non-Reimbursable Foods Inventory for the whole week.
•
Be sure to inventory foods and beverages that are non-perishable, refrigerated,
and frozen. Take into account all items in storage areas that are accessed
during the week, plus items that are already out for sale. You do not need to
count items in storage areas that are not accessed during the target week.
•
Be sure to look at the sample completed Non-Reimbursable Foods Inventory
that is provided. Looking at this sample as you read the instructions will make it
easier to understand what you need to do when filling out the form.
How to Complete the Non-Reimbursable Foods Inventory
Meal
At the top of the form, check the appropriate box or boxes to indicate when any nonreimbursable foods are offered: during breakfast, lunch, and/or outside of meal periods.
Foods may be offered outside of meal periods, just one time, or throughout the day.
Where Offered
Non-reimbursable foods may be sold on cafeteria serving lines or in other venues, such
as vending machines, snack bars, school stores, or food carts or at another school or
facility off-site. Indicate the venues where the non-reimbursable food items listed on this
form are offered, checking all boxes that apply. If the food service department sells nonreimbursable foods in a venue that is not listed, check “Other,” and write in the name of
the venue.
30
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Column A: Food Name
At the start of the week, use this column to list all non-reimbursable items that are sold
across all venues. Creating a list of items at the start of the week will make the form
easier to fill out.
If food items are purchased in a variety pack (for example, different flavors of
Gatorade), you can list the items once.
Column B: Individual Package Size
For each food items listed in Column A, record the size of the package, which represents
one individual serving. The individual package size should include both the amount and
the unit of measure (such as 12 fl. oz. for a drink). If a food item is available in more than
one size, you will need to list the food twice (on separate lines) and record in both package
sizes for that item.
Column C: # Individual Packages in Bulk Case
Also for each food item, record the number of individual packages that exist in a single
bulk case.
Column D: Manufacturer/Brand Name and Product Code
Use this column to record the manufacturer or brand name and a product code (if
available) in Column D.
Column E: Starting Onsite Inventory
For each food item, provide the starting inventory at your school. Include the counts of
items in the stock room, refrigerator, freezer, and other storage areas, plus the number
of items already put out for sale. You will record any deliveries received on Monday in
Column F. You do not need to count items in areas that are not accessed during the target
week.
# Full Bulk Cases
Record the number of full bulk cases that are in the inventory of the venues selling nonreimbursable foods at the beginning of the day on Monday, before any of the food
service venues have opened.
# Additional Individual Packages
Record the number of additional individual packages on hand that do not make up a full
bulk case. For example, there may be eight 48-carton bulk packages of orange juice, and
10 additional cartons left over from a bulk package that had already been opened.
31
INSTRUCTIONS FOR EXPANDED MENU SURVEY
Column F: Deliveries
For each food item, record the number of full bulk cases and/or fractions of full cases (for
example, 1/2 or 2 1/2 cases) that are received each day (Monday through Friday) of the
target week and added to the amounts on hand that you recorded in Column E. If your
school sends non-reimbursable items to other schools or facilities during the week, enter
the number of bulk containers sent off-site in the columns provided.
Enter zeros on days when there are no deliveries, or no bulk containers sent off-site.
Column G: Ending Onsite Inventory
For each food item, provide the ending inventory at your school, after all of the food
service venues have closed and after any deliveries on Friday. Include the number of
items in the stock room, refrigerator, freezer, and other storage areas, plus the number
of items already put out for sale.
# Full Bulk Cases
Record the number of full bulk cases that remain in the food service inventory at the end
of the week, after all deliveries and sales. Be sure to count all of the storage areas that
were included in the count at the start of the week.
# Additional Individual Packages
Similarly, record the number of additional individual packages on hand at the end of the
week.
32
This page has been left blank for double-sided copying.
0MB Control Number: 0584-xxxx
Expiration Date: xx/xx/xxxx
S�rG6
Daily Meal Counts Form (Expanded)
JDnlt\ � cv0+1'l vYl d,c{ Le
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=---
Date:,_-'-,
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School Name:
lnsuucuons:
D
• School Nutrition &
Meal Cost Study- II
1.
In the boxes for the Number of Reimbursable NSLP Lunches Served and Number of Reimbursable SBP Breakfasts Served, please
record the number of free, reduced-price, and full-price reimbursable meals served in your school each day of the target week. Do not
include meals for which you do not claim reimbursement, for example, second lunches sold to students on an a la carte basis. If your school
provides free meals to all studen;s, record the number of meals served in the "free" column.
2.
Check the box if the number of reimbursable meals served on a day was much higher or lower than usual, and describe the reason for this
difference in the space provided.
I
,i.Ss
ReducedPrice
Free
Monday
Tuesday
Wednesday
Thursday
Friday
23
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82.
2-
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7'6
ii
Number of Relmbur�able NSlP lunches Served
FullPrice
30
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Please check if the number of reimbursable lunches
served this day was much higher or lower than usual.
FOR,OFFICE
USE ONLY
□
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Number of Reimbursable SBP Breaklas1s Served
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30
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Monday
11
Tuesday
oo
Wednesday
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0
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0
0
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2..
Manufacturer/Brand Name and
Product Code
(If Aoolicab/e)
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0
i'Fat-free/skim
01%
02%
0 Fat-free/skim
01%
02%
0 Fat-free/skim
01%
02%
fl oz.
fl oz.
fl oz.
USDA
',=
D
D
D
D
D
D
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
A.
B.
D.
C.
E.
G.
F.
Number of Portions
Onsite
Portion
Size
(Include
Units)
Food Item
FRUIT
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over
for
Later
Use
Wasted
(Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, complete a RECIPE FORM.)
Annie, fresh
Aoolesauce, canned
cup
Apricots, canned
cup
I ntedivr,1
Banana.fresh
Blueberries, frozen
cup
Fruit cocktail, canned
Grapes, fresh
'/ Z.. cup
Ifi CUP
�o
Lf <.::
0 "C
Ill "'
.r:
.r: .. "'
.,."
Manufacturer/Brand Name and
Product Code
(If Applicable)
-
-
�
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□
□
□
□
□
□
□
□
□
□
□
□
□
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
A.
B.
C.
E.
D.
G.
F.
Number of Portions
Onsite
Portion
Size
(Include
Units)
Food Item
JUICES
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over
for
Later
Use
::::>
:: "C
X 0
0 0
...
Cll u..
Manufacturer/Brand Name and
Product Code
(If Applicable)
Wasted
u
Cl>
Food Description
(Note: Prelisted entries should be used only for full-strength (100%) fruit and/or vegetable juice. List fruit drinks (not 100% juice) in the "Other Menu Items" section.)
Lf
Apple juice
fl oz.
Grape juice
fl oz.
Orange juice
fl oz.
Fruit juice blend
fl oz.
BREADS AND GRAINS
l
Cheerios, plain
oz.
oz.
Cheerios, Apple Cinnamon
oz.
Cheerios, Fruity
oz.
Cheerios, Honey Nut
Cinnamon Toast Crunch
)
oz.
oz.
Cocoa Krispies
oz.
Cocoa Puffs
oz.
Froot Loops
oz.
Frosted Flakes
oz.
Frosted Mini Wheats
oz.
Golden Grahams
oz.
Granola
oz
Kix
oz.
Lucky Charms
oz.
Marshmallow Mateys
oz
Rice Chex
Rice Krispies
-z.i
z_
0
UCalcium added
□ Calcium added
□ Calcium added
□ Calcium added
-
(.)
□
□
□
□
□
(Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination Item. For example, toast w/ cereal).
Apple Jacks
Raisin Bran
!-iO
/0
�
I
oz.
oz
zo
I(
0
q
D
'li)
IQ
0
-,
0
□
□
□
□
□
D
□
□
□
..
D
□ Reg □ Low-fat
□
□
D
I D
�
'L
D
□
□
□
0
D
oz.
D
3
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...
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·- 0
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.....
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□
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
B.
A.
C.
E.
D.
G.
F.
Number of Portions
Onsite
Portion
Size
{Include
Units)
Food Item
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over
for
Later
Use
::i
!: "O
>< 0
0 0
m IL
Manufacturer/Brand Name and
Product Code
Wasted
-"'
0
Food Description
(If Applicable)
(.)
oz.
Trix
0
>< .::
0 "C
m .,
�-�
s: ..
-"'
..
Cl)
(.)
Cl)
Cl)
0
Cl)
(.) 0. 0::
D
(Note: If prepared with fat and/or milk, complete a RECIPE FORM)
HOT CEREALS
Ill
,._
E
·-
~
-
-
--
--
--D Quick
D Reg
-
D
D
D
D
D
D
D
Cream of Wheat
cup
D Instant
Grits
cup
D Instant
D Quick
D Reg
D
D Instant
D Quick
!ifReg
D
d
D
D
I
Oatmeal
cup
S""
4
0
0
r
OTHER BREADS AND GRAINS OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meaUmeat alternate or combination item. For example, toast
w/ cereal, or biscuit w/ sausage).
Bagel
v1 I vua
Biscuit
fl* �!Al-er 3
oz.
(p
0
[)
0
Specify type:
Doughnut
v'l ur-ev(
oz.
11..,'2.... oz.
English muffin, plain
oz.
English muffin, buttered
oz.
Granola/cereal bar
oz.
v1 I Uv't-OJ
1....
oz.
IS-
13
1--
()
0
0VIt10.f 'oa� ,v1
�
fo 00 l
/Cf
D
(
0
i,J� b U
Wvu tv{-
D
D Fruit
□ Cheese
D
mcing/glaze
D No Icing/glaze
D
SO-R- lee --#=-f-i C, I I
D Butter
Specify type:
oz.
Roll, cinnamon
oz.
D Icing
Toast, plain
oz.
Specify type:
Toast, buttered
oz.
Specify type:
□ Margarine
Toaster pastry
oz.
□ Low-fat
D
D
□
Specify type:
Pancake
4
D
□
D Margarine
II
1,,,0
IO o·r.
D
oz.
Danish or turnover
Muffin
(p
I Q(Af� btVt �
D No Icing
D
D
D
D
D
D
D
□ Butter
□
D
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
A.
B.
D.
C.
G.
F.
E.
Number of Portions
Onsite
Portion
Size
(Include
Units)
Food Item
Waffles
oz.
Waffle sticks
ea.
Total
Prepared
cup
Ham
oz.
Ina rA,e;\
a
Yogurt
1
oz.
{p
oz.
&
0
0
EgA sandwich
sandwich
□ Plain □ Fruit □ Chocolate chip
□ Other:
oz.
0 't:I
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"'... ""'
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.:,,:
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"' [ .e-
.r.
t.) Q. 0::
□
□
□
□
□
□
□
□
□
□ Eggs □ Cheese □ Beans □ Potato □
Other:
V>
D
0
0
J\,1S v0
-de '--fl,�
Q'Cheese
□ Bacon
�ausage
□ Other:
0'
□
□
□ Cheese □ Sausage □ Ham
□ Bacon □ Other:
Specify bread type:
5
-
-
□ Ham
Specify bread type: ,,J�l{k-{YL/i\11 i Vl
□
□
Specify flavors:
�o
0
x�
□
□ Beef or pork □ Chicken or turkey
□ Reg □ Low-fat □ Fat-free □ Light
oz.
Egg sandwich
t.)
WReduced-fat
0
-
1
.sam:lwreh
Food Description
□ Turkey
□ Pork
□ Scrambled □ Hard boiled
□ Fried
□ Pork
□ Turkey
oz.
3,s'
o-i
""'
...
E
·-
(Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meaUmeat alternate or combination item. For example, sausage with
COMBINATION ITEMS
Breakfast burrito
Wasted
sl
EgQs
Sausage
Manufacturer/Brand Name and
Product Code
(If Applicable)
>< 0
0 0
Ill LL
.:,,:
Weight of each stick:
MEATS AND MEAT ALTERNATES OFFERED SEPARATELY
Peanut butter IAI
Reimbursable
Served
:t 't:I
□ Plain □ Fruit □ Chocolate chip
□ Other:
biscuit, or yogurt with cereal).
Bacon
Sent
Off-Site
Served A La
Carte or to
Adults/Others
:::)
Left
Over
for
Later
Use
Wl u-{-,f-ff\
□
□
□
□
□
□
□
□
□
□
□
□
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
A.
B.
C.
D.
E.
F.
G.
Number of Portions
Onsite
Portion
Size
(Include
Units)
Food Item
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adu Its/Others
::>
Left
Over
for
Later
Use
:-!:: 'C
)( 0
0 0
IXl u..
Manufacturer/Brand Name and
Product Code
(If Applicable)
Wasted
French toast sticks
ea.
Grilled cheese
Pancake on a stick
Weight of each stick:
1
sandwich
2.. C" oz.
Pizza
10
°{
I
0
0
D Reduced-fat
Sta.\.e �(
'"'7-0CPO I
oz.
Self-serve condiments or fixins'
bar
=
-
-
serving
__,::_
□ Reg □ Red.fat □ Light □ Fat-free
□ Reg □ Red.fat □ Low-fat □ Fat-free
Gravy
Honey
l
D 1.,.-
ID
�
D
s-
Cl> ()
Cl> ...
,::;;
Cl>
n. Cl::
□
0
□ Sugar-free
2,01.--
lD
q
I
D
□
□
□
□
□
□
□
□
o� I'\ r,t\ ite
□
□
Margarine
v,1 r
□
□
□
Syrup
[.2-
□
Ketchup
Salsa
0
u
�
1=-::,
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
Cream cheese
()
□
□
□
□
·-
Butter
Jelly
ufBeef or pork □ Chicken or turkey
□ Reduced-fat
Specify toppings:
-
CONDIMENTS
oz.
0 "C
m Cl>
-" ... Cl>
□
□
□
□
□
French toast
X.)::
-"'
()
Food Description
«>
_e
·- 0
0
□ Low sodium
□
�ugar-free
□
□
6
□
□
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
A.
B.
D.
C.
E.
G.
F.
Number of Portions
Onsite
Food Item
tl(�Jr n-Gi o
vraa.�st
Portion
Size
(Include
Units)
I b-ox
Total
Prepared
Lf
Sent
Off-Site
Reimbursable
Served
Lf-
Served A La
Carte or to
Adults/Others
()
=>
Left
Over
for
Later
Use
0
·- "C
X 0
0 0
Manufacturer/Brand Name and
Product Code
(If Aoo/icable)
Wasted
0
m u.
·- 0
x.::
0
""
m -cCl>
"" .. Cl>
u [.e-
(.)
011.0::
0
Food Description
.,
... E
Cl>
.c
Cl>
..
D
ef
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
D
OTHER MENU ITEMS
7
0
Cl>
0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
SCHOOL NUTRITION AND MEAL COST STUDY-II
Reimbursable Meal Counts
How many reimbursable lunches did you plan to serve at your school this
day?
How many reimbursable lunches did you serve at your school this day?
Joh
Jwi--itn
,dd
,is
(.e,
School Name:-----=--'--'-------'C---'-'-----------m
VI.
--- Date:
A.
B.
0
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
100
• School Nulritlon &
Meal Cost Study· 11
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
1
/(I
{ a)
Day:
C.
0'Mon
□ Tue
□ Thu
□ Wed
E.
D.
Number of Portions
Portion
Size
(Include
Units)
Food Item
MILK
i
While, fat-free/skim
0 -0
al
-"'
Ql
...
w
lat
\V'V11
..,
i
fl oz.
2--1
0
02%
fl oz.
□ Fat-free/skim □ 1%
02%
fl oz.
□ Fat-free/skim □ 1%
02%
-�at-free/skim
fl oz.
□
□
fl oz.
□
□
fl oz.
□
□
USDA
-o-=
CJ
Ql
UD..0::
II
□ 1%
fl oz.
Ql
�.e-
CJ
Ql
Ql
.c ...
fl oz.
Chocolate, 2%
Other flavo
Sh'li,
Specify:
fl oz.
Total
Prepared
F.
XO
Onsite
Served A La
Carte or to
Adults/Others
□ Fri
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
A.
D.
C.
B.
E.
Number of Portions
Food Item
FRUIT
Portion
Size
(Include
Units)
,�.
!t:
><
0
00
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Manufacturer/Brand Name
and Product Code
(If Ann/icable)
'O
0
0
LL
.:.:<
0 "C
00
.:.:
CJ
(1)
..c:
(1)
..
(1)
(1)
..
...
(1)
[.e-
(.) 0.. a::
(Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, complete a RECIPE FORM.)
Apple, fresh
Applesauce, canned
'/Z..
Apricots, canned
cup
�
JO
,;- 0
17
0
- -,
()
C}
2-
Lf
D
D Sweetened
�sweetened
D Light syrup
D Heavy syrup
D Extra light syrup D Juice
□ Water
cup
Blueberries, frozen
Fruit cocktail, canned
Grapes, fresh
\/z
D Sweetened
□ Unsweetened
□
□
cup
D Light syrup
D Heavy syrup
D Extra light syrup □ Juice
D Water
cup
9)
e;-D
0
0
0
D
D
D Light syrup
D Heavy syrup
D Extra light syrup D Juice
□ Water
cup
□ Heavy syrup □ Light syrup
□ Extra light syrup D Juice
□ Water
cup
Pineapple, canned
D
□
Pears, fresh
Pears, canned
D
D
Orange, fresh
Peaches, canned
D
cup
Kiwi, raw
Mandarin oranges, canned
c/
D
Banana,fresh
Raisins
F.
cup
ti./ Cf£_
cup
�
t-{ (
lf
0
)
2
□ Heavy syrup D Light syrup
□ Extra light syrup D Juice
□ Water
D
D Light syrup
D Heavy syrup
D Extra light syrup D Juice
□ Water
D
D
□
D
□
□
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
A.
B.
C.
D.
E.
Number of Portions
Food Item
JUICES
Portion
Size
(Include
Units)
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
"'
... E
� 'tJ
>< 0
0 0
Onsite
Total
Prepared
G.
F.
Left Over for
Later Use
Wasted
Ill u.
-><
0
Ill
0
,l::
'O
a,
ti::>
..,.
...
Q)
Q)
.c
Q)
...
Q)
'-'o
Manufacturer/Brand Name
and Product Code
(If A,:,,:,/icable)
(.) [.e(.)
Q) (/)
Food Description
(.) Q. 0::
(Note: Prelisted entries should be used only for full-strength (100%) fruit and/or vegetable juice. Fruit drinks that are not 100% juice should be entered in the "Desserts, Drinks, and Snacks" section.)
Apple juice
fl oz.
□ Calcium added
Grape juice
fl oz.
Orange juice
fl oz.
□ Calcium added
□ Calcium added
Fruit juice blend
fl oz.
□ Calcium added
Frozen juice cup/bar
fl oz.
Specify flavor:
fl oz.
□
□
□
□
□
□
□
□
□
VEGETABUS (Note: If beans or peas are being counted as a meat alternate and not a vegetable choice, enter them in the "Other Entrees and Meat/Meat Alternates" section.)
Baked beans
Beans, green
Broccoli, cooked
□ With pork
□ Vegetarian
□ Fresh □ Frozen
□ Canned □ Low sodium
□ Fat added, specify type:
cup
cup
'fz.
cup
Broccoli, raw
cup
Carrots, cooked
cup
Carrots, raw
cup
Cauliflower, raw
cup
Celery, raw
cup
Corn, kernels
cup
Cucumber, raw
cup
3D
3D
0
0
0
□ Fresh B"Frozen
□ Canned □ Low sodium
D Fat added, specify type:
If offered, list dip as separate item(s) or complete a RECIPE FORM
□ Fresh □ Frozen
□ Canned □ Low sodium
□ Fat added, specify type:
If offered, list dip as separate item(s) or complete a RECIPE FORM
If offered, list dip as separate item(s) or complete a RECIPE FORM
If offered, list dip as separate item(s) or complete a RECIPE FORM
□ Fresh □ Frozen
□ Canned □ Low sodium
□ Fat added, specify type:
If offered, list dip as separate item(s) or complete a RECIPE FORM
3
□
□
□
□
□
□
D
□
□
□
□
□
□
□
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
A.
B.
D.
C.
Number of Portions
Food Item
Portion
Size
(Include
Units)
French fries
cup
Lettuce and tomato
cup
Mixed vegetables
'/i,
cup
Peas, green
cup
Potatoes, whipped or mashed
cup
Refried beans
Red peppers, raw
Green peppers, raw
Y4
cup
30
'30
Sent
Off-Site
Reimbursable
Served
Io
rq
2-
7
� 'O
E
...
·- 0
x.:=
llJ IL
Left Over for
Later Use
Manufacturer/Brand Name
and Product Code
(If Aoo/icable)
Wasted
4
D
o Cl
(1) Cl)
Food Description
(3::>
□ Oven-baked □ Deep-fried
□ Fresh (l;l'trozen
□ Canned □ Low sodium
□ Fat added, specify type:
I8
0
� <(
vn
t.A,.YT,t n.
□
0 'C
llJ
�
(1)
.c:
..
.. (1)
[.!:!0
(1) (1) 0
□ From fresh
□ From dry Q'canned
O'[.ow sodium
□ Fat added, specify type:
□
□
D
□
D
□
If offered, list dip as separate item(s) or complete a RECIPE FORM
D
cup
If offered, list dip as separate item(s) or complete a RECIPE FORM
D
□
□
□
□
cup
Sweet potato fries or tots
cup
1 serving
Salad, tossed
cup
Tater tots or shapes
cup
Tomato, raw
cup
□ Fresh □ Frozen
□ Canned □ Low sodium
□ Fat added, specify type:
□ Oven-baked
I s-z>
{( 0
3S-
0
�
□ Deep-fried
□ Oven-baked □ Deep-fried
If offered, list dip as separate item(s) or complete a RECIPE FORM
4
□
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
List dressing and any bread/grain items offered with the tossed salad
as separate item(s)
D
(1)
(J 0.. 0::
ri r...t-
□ Fresh - □ Frozen
□ Canned □ Low sodium
□ Fat added, specify type:
11
□
□
IV
cup
Sweet potatoes
Side salad bar
(non-entree or small portion)
Total
Prepared
G.
X 0
0 0
Onsite
Served A La
Carte or to
Adults/Others
F.
E.
□
□
D
□
D
□
D
□
□
□
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
C.
B.
A.
D.
E.
Number of Portions
Portion
Size
(Include
Units)
Food Item
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Manufacturer/Brand Name
and Product Code
(If Armlicable)
F.
G.
� 'C
>< 0
0 0
Ill LL
.><,:X:
·- 0
>< ,l:
0 -0
Ill"'
... 0
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Food Description
<}::>
< 0
0 0
m LL
Onsite
Served A La
Carte or to
Adults/Others
F.
Left Over for
Later Use
Manufacturer/Brand Name
and Product Code
(If Aoolicable)
Wasted
.,. <(
uo
OJ (/)
Food Description
c3::,
sandwich
sandwich
EHTREE SALADS
0
>< .::
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m (l)
.,. ... OJ
0 [.e-
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.c
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(.) n. 0::
□
□
□
□
(Note: List dressing and any bread/grain items offered with an entree salad as separate item(s). Also, add a note in Column A if a particular bread/grain item is offered only with a particular entree salad.)
Chefs salad
1 salad
□
□
Chicken Caesar salad
1 salad
□
□
Taco salad
1 salad
□
□
t1r-eR,IC.�Cl,lrui wtr.M.;-�vi
1 salad
{p
/).__
3
1
0
□
-er
□
1 salad
□
1 salad
□
□
1 salad
□
□
1 salad
□
□
□
□
1 salad
II
SElF-SERVE/MADE-TO-ORDER EHTREE BARS
Entree salad bar
1 serving
Potato bar
1 serving
Nacho/taco bar
1 serving
Sandwich/deli bar
1 serving
Pasta/Italian bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
31
2--�
c;-
0
8
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
6
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
A.
8.
C.
D.
F.
E.
Number of P ortions
Food Item
Portion
Size
(Include
Units)
� "C
>< 0
0 0
al LL
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or t o
Adults/Others
Left Over for
Later Use
Wasted
-"'
II)
Food Description
G.
"'
E
...
·-
0
,l::
"O
Cl)
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><
0
al
..,.
0 [.eCl) Cl) 0
.c: ... Cl)
(.) Q. 0::
OTHER ENTRIES AND MEAT/MEAT ALTERNATES (Note: In Column A, indicate whether any items in this section were offered only with another particular food item. For example, a cheese stick with a peanut butter sandwich, a yogurt with a grilled cheese
sandwich, or chicken nuggets with a roll).
Beans or peas
(Specify type)
Burrito
cup
�-q
oz.
'2-8
U>
0
oz.
Cheese (string cheese or cubes)
Cheese breadstick or pizza stick
□ From dry D Canned
□ Low sodium □ Fat added, specify type:
r
0
� frt �Ylf.{ � s
I
4 0 2,,1--
oz.
Chicken nuggets (breaded)
ea.
Chicken strips (not breaded)
oz.
Chicken patty (not sandwich)
oz.
ef°Bean
□ Chicken
D Beef
�heese
□
D
□
D Reduced-fat
D
D Reduced-fat
Specify fillings:
□
D Oven-baked
D Deep-fried
Weight of each
oz.
nugget:
□
□
□ Oven-baked
Chicken piece(s)
(Specify part)
D Breaded
□ Oven-baked
Corndog
□
□
□ Deep-fried
□ With skin
□
D Deep-fried
D Beef or pork
D Chicken or turkey
oz.
□
D
□ Meatless
ea.
D Beef or pork
D Chicken or turkey
Weight of each egg roll:
Fish sticks or nuggets
ea.
D Breaded
Weight of each
nuggeUstick:
Macaroni and cheese
cup
□
□
Nachos
oz.
□
□
Peanut butter
oz.
Egg rolls
Pizza, cheese
Pizza, pepperoni
s-.s-
oz.
l{, qi oz.
□ Oven-baked □ Deep-fried
oz.
u
so
'vl
0
l-{
0
0
0
0
7
To'1<'{J
7V,1(
Ton'1 S 715 3 Co�
□
D
oz.
D Reduced-fat
30
□
D Reduced-fat
□ Thick crust (deep-dish, bagel, French
bread)
D Reduced-fat
□ Thick crust (deep-dish, bagel, French
bread)
D
D
□
□
□
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
A.
C.
B.
E.
D.
F.
Number of Portions
Portion
Size
(Include
Units)
Food Item
:t:
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
oz.
Pizza, sausage
Pizza, vegetarian
oz.
Pizza pocket
oz.
Stir fry with rice or noodles
cup
Spaghetti with sauce
viIVt? r I
I
I
cup
(JI/ (JearuA- �
oz.
�tAYld 1M CiVl
<>c
., en
(3::>
Food Description
0
b
�
0
0
0
□
□
□
□
□
□
□
□
□
g/'
D
□
protein}
Specify fat:
□ Whole Mow-fat
□ Fat-free □ Light
\//YI 1'/ ( A
Specify flavors:
D
□
D
BREADS AND GRAINS OFFERED SEPARATELY (Note: In Column A, indicate wheter any items in this section were offered only with a particular entree or meaVmeat alternate. For example, crackers with Chefs salad or a roll with chicken nuggets.}
Biscuit
oz.
Bread, plain
oz.
□ Reduced-fat
Specify type:
Bread, butlered
oz.
Specify type:
Margarine
Breads tick
oz.
Specify type:
Cornbread
oz.
Corn/tortilla chips
oz.
Crackers
Croutons
Rice
Roll
uJ I {)\ (t(, Ile('64.,(au{
vJ\ .,Of,\G\VV\tAn
'1
I
ea.
oz.
cup
oz.
□
&
,r
2-
IY
j
0
I
0
0
(
8
... .,
., a.., .e-"
(.J
.c ... .,
0 0. 0::
□
ifMeat sauce
□ Marinara sauce
□ Hard shell □ Soft tortilla
□ Bean
D Beef
□ Chicken □,Cheese
Specify type: [];'Regular □ Greek (high
(
f)
0
>< .::
0 ,::,
Ill .,
.:,,:.
D
□
IL/
..
�E
·-
□ Reduced-fat
□ Thick crust (deep-dish, bagel, French
Reduced-fat
Specify filling:
Taco
Yogurt
Manufacturer/Brand Name
and Product Code
(If Aoolicable)
Ill U..
.:,:.,ct
bread}
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
Specify toppings:
,�
,::,
>< 0
0 0
G.
Specify type:
□ White
□ Butter
I,./h, Lt
D Brown
Specify type:
t-
1111. 1--.t t\.,
□ Wild
IAIV!At.e,
□
□
□
□
□
□
□
□
□
□
□
□
□
D
□
□
□
□
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
A.
C.
B.
E.
D.
Number of Portions
Food Item
Portion
Size
(Include
Units)
Pasta
cup
Pretzels
oz.
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
G.
OI
� "C
)( 0
0 0
Onsite
Total
Prepared
F.
IXl IL
Left Over for
Later Use
Wasted
.>
"" E
·0
)(
0
�
,,
IXl a,
"" ... a,
0
[.e.
a, a, u
a,
.c ...
a. 0::
u
D
D Soft
D Salted
D Hard
D Unsalted
D
D
D
D
D
D
D
DESSERTS, DRINKS. AND SHACKS OFFERED AS PART OF A REIMBURSABLE MEAL
Brownie
D Icing
D
D
Cake
Specify type:
D
D
Specify type:
D
D
Specify type:
D
D
fl oz.
Specify type:
D
Fruit turnover
oz.
Specify type:
D
D
Gelatin
cup
D With fruit
D With whipped topping
D
D
Potato chips
oz.
D Reduced-fat
D
Cookie
oz.
Fruit crisp or cobbler
Fruit drink (not 100% juice)
D Baked
D
D
D
D
SALAD DRESSINGS
Caesar dressing
D Reg O Light D Red. calorie
D Fat-free
D
D
French dressing
D Reg D Light D Red. calorie
D Fat-free
D
D
Honey mustard dressing
D Reg D Light D Red. calorie
D Fat-free
D
D
Italian dressing
D Reg D Light D Red. calorie
D Fat-free
D
D
Ranch dressing
D Reg D Light D Red. calorie
D Fat-free
D
D
9
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
A.
C.
B.
E.
D.
Food Item
Glv,t � �JOJ kl"lll'I\
2-1b�
CONDIMENTS
Self-serve condiments or fixins' bar
1 serving
� "C
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
VJ
2
3
lll'1
J7f
IS-
G.
ns
Number of Portions
Portion
Size
(Include
Units)
F.
:t
� <(
� ... .,
al u.
Left Over for
Later Use
I
Manufacturer/Brand Name
and Product Code
(If Aoo/icab/e)
Wasted
0
., VJ
□
□ Reg □ Light □ Red. calorie
□ Fat-free
u
?-q
oo
Food Description
ilt'Reg Light D Red. calorie
D Fat-free
§
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□
D
□
□
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
Barbeque sauce
Butter
D Reg D Red. fat
□ Fat-free
D Reg □ Red.fat
Cream cheese
D Fat-free
Gravy
□ Low-fat
D Low-fat
Hot sauce
Jalapeno peppers
D
□
□
□
□
□
□
Honey
□ Sugar-free
Jelly
□
□
D
Ketchup
Margarine
I
Mayonnaise
□ Reg □ Red.rat □ Low-fat
□ Fat-free
Mustard
Pickles, slices
□
Red.fat D Low-fat
0 Reg
D Fat-rree
Ranch dip
Relish
□ Low sodium
□ Reg □ Red.fat
Salsa
D Fat-free
Sour cream
D Low-fat
D
□
□
□
□
□
□
□
D
Syrup
D Sugar-free
D
Tartar sauce
D Reg D Red. fat D Low-fat
D Fat-free
D
10
□
D
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
A.
C.
B.
0.
E.
Number of Portions
Food Item
Portion
Size
(Include
Units)
!t: 'O
>< 0
0 0
en .._
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
F.
Left Over for
Later Use
Wasted
Manufacturer/Brand Name
and Product Code
(If Aoo/icable)
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0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
D
Recipe Form (Expanded)
*
• School Nulrillon &
Meal Cost Study - II
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu SuNey.
School Na� JQ Vl
Meal:
Day:
Breakfast
1
□ Mon
1
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0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
D
Recipe Form (Expanded)
• School Nut�llon &
Meal Cost Study -11
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
J Yl n J Wt, f--ht\
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School Name:
1 □ Breakfast
Meal:
Day:
1izrMon
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2 D Tue
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Size of One Serving (include units):
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A.
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Recipe
(Include
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0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
D
Recipe Form (Expanded)
• School NutrHJon &
Meal Cost Study -11
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
John
School Name:
1 D Breakfast
Meal:
Day:
1
s
□ Mon
litAII
20'Lunch
2 0 Tue
A.
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C.
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0MB Control Number: 0584-XXXX
Expiration Date: XXJXXJXXXX
n
Recipe Form (Expanded)
• School Nulri1lon &
Meal Cost Study -11
NO TE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
JovtV\ Swt,+vt VYtrJo< Le
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Number of Servings Prepared:
2-t.f
School Name:
1 □ Breakfast
Meal:
Day:
10 Mon
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Recipe
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Meal Cost Study- II
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Meal Cost Study -11
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Meat Cost Study -11
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu SuNey.
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• School Nutrition &
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• School Nutrition &
Meal Cost Study -11
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
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Meal:
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SCHOOL NUTRITION AND MEAL COST STUDY-II
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• School Nutrition &
Meal Cost Study -11
NSLP Afterschool Snack Form (Expanded)
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name:
1.
J-o h V\ S-rvt AA
WH Ld(l
Please indicate the days that NSLP afterschool snacks were prepared or served during
the target week:
d'" Monday
□
Tuesday
� Wednesday
ef
□
Thursday
Friday
USDA
.iia
This page has been left blank for double-sided copying.
NSLP Afterschool Snack Form (Expanded)
Day:
J'Mon
□ Tue
A.
□ Wed
□ Thu
Number of Reimbursable Snacks Served Onsite:
D Fri
B.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Onsite
Sent
Off-
Site
Reimbursable
Prepared/
Available
Reimbursable
Served
Manufacturer/Brand
Name and Product Code
(If Aoo/icable)
fl oz.
Chocolate
fl oz.
Other flavor, Specify:
fl oz.
Other flavor, Specify:
fl oz.
Fruit
-
Apple, fresh
Aoolesauce, canned
CUD
Banana, fresh
Fruit cocktail, canned
---
Food Description
Juices
Aonle iuice
Oranoe iuice
Grape juice
(n
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□ Unsweetened
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A.
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Number of Portions
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D.
C.
Site
Reimbursable
Prepared/
Available
0
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Served
Manufacturer/Brand
Name and Product Code
(If Aoo/icable)
<(
C
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Ve�etables (if offered with a dip, list the dip as a separate item in the condiments section)
Carrots. raw
CUP
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cup
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Pizza
Sandwich
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F.
□ Whole grain-rich
□ Whole grain-rich □ Reduced-fat
1 sandwich
Specify toppings:
oz.
□ Whole grain-rich
1 sandwich
Meat and Meat Alternates
□
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Reduced-fat
Specify type:
□
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oz.
Specify
ingredients:
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oz.
Specify flavor(s):
2
·u
□
□
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□
□
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Cheese
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□ Light
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NSLP AFTERSCHOOL SNACK FORM (EXPANDED)
A.
B.
D.
C.
F.
E.
Number of Portions
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Portion
Size
(Incl.
Units)
0
Onsite
Sent
Off-
Site
Reimbursable
Prepared/
Available
LL.
Reimbursable
Served
Manufacturer/Brand
Name and Product Code
(If Aoo/icable)
Breads and Grains
Baael
oz.
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oz.
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oz.
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oz.
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Specify type:
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4K
-
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type:
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D Whole grain-rich
D Soft
D Hard
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D Salted
D
D Whole grain-rich
D
D
D Whole grain-rich
D
D
D Whole grain-rich
D
D
D
Desserts and Other Items
D
Fruit snacks/fruit leather
Fruit drink /less than 100% juice)
□
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Puddina
Condiments
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Ketchup
3
Specify flavor(s):
D
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D Reg □ Red. fat D Low-fat
□ Fat-free
D Reg D Red. fat D Low-fat
D Fat-free
□
□
□
□
□
□
NSLP Afterschool Snack Form (Expanded)
Day:
□ Mon
□ Tue
£wed
□ Thu
□ Fri
Number of Reimbursable Snacks Served Onsite:
B.
A.
E.
D.
C.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
fl oz.
Chocolate
fl oz.
Other flavor, Specify:
fl oz.
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fl oz.
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O 0
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Available
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D
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D Sweetened
cup
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D
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D Water
□
cup
-
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-
-
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(_p
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fl oz.
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fl oz.
e;--o
40
�alcium added
-
--
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--
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D
D
D
D
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□
D Calcium added
D
D
D
NSLP AFTERSCH00L SNACK FORM (EXPANDED)
A.
B.
C.
E.
D.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Reimbursable
Prepared/
Available
G.
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0
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LI..
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<
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w I (Cf rtr,n ir¥?
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cup
$0
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D
D
D
D
D
D
D
D
D
D
D Whole grain-rich
D
D
D Whole grain-rich D Reduced-fat
Specify toppings:
D
D Whole grain-rich
D
D
D
D
D
D
D
D
D
D
Combination Items and Entrees
Peanut butter & iellv sandwich
Pizza
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1 sandwich
oz.
1 sandwich
Meat and Meat Alternates
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Trail mix
oz.
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---
-
D Reduced-fat
Specify type:
Specify
ingredients:
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D Light
Specify flavor(s):
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2
D
D
D
D
D
D
D
D
D
D
D
D
D
D
NSLP AFTERSCHOOL SNACK FORM (EXPANDED}
A.
C.
B.
E.
D.
Food Item
0
0
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OffSite
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Prepared/
Available
G.
<'-·
Number of Portions
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Size
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F.
LL
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Name and Product Code
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<(
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-
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-
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Specify type:
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D Whole grain-rich
Specify type:
D
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Cereal
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Cookie
oz.
Corn/tortilla chios
oz.
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Specify type:
D Whole grain-rich
Specify
type:
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ea.
D Whole grain-rich
Specify type:
D
Granola bar
oz.
D Whole grain-rich
Specify type:
D
□ Soft
D Whole grain-rich
D Hard
D Unsalted
D Salted
D
D Whole grain-rich
D
D
D Whole grain-rich
D
D
D Whole grain-rich
D
D
□
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oz.
Pretzels
D
D
D
Desserts and Other Items
D
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D Fat-free
D Reg D Red. fat D Low-fat
D Fat-free
D
D
D
D
D
D
D
D
D
D
Ketchuo
D
3
D
NSLP Afterschool Snack Form (Expanded)
□ Mon
Day:
□ Tue
□ Wed
□ Fri
�hu
A.
Number of Reimbursable Snacks Served Onsite:
B.
E.
D.
C.
Number of Portions
Food Item
Portion
Size
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Site
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Chocolate
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fl oz.
fl oz.
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S-0
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01%
02%
0
01%
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0
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01%
02%
0
fl oz.
0 Fat-free/skim
01%
02%
0
0
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Aoolesauce, canned
0 Sweetened
CUP
Banana. fresh
Fruit cocktail. canned
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I
CUP
1 /z...evo
oz.
I / 'l r, iNJ
Juices
Aoole iuice
fl oz.
Orange juice
fl oz.
Grape juice
fl oz.
'7
s--
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□ Unsweetened
□ Light syrup
□ Heavy syrup
□ Extra light syrup □ Juice
□ Water
l�ld t"A-l..S
v
-FY€; Y1
□ Calcium added
□ Calcium added
□ Calcium added
0
0
0
0
□
□
□
□
□
□
□
□
□
□
Q,)
u .. a::
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□
NSLP AFTERSCHOOL SNACK FORM (EXPANDED)
A.
B.
D.
C.
Number of Portions
Food Item
VeQetables
Portion
Size
(Incl.
Units)
E.
F.
C'•
Onsite
Sent
Off
Site
Reimbursable
Prepared/
Available
cup
Celerv, raw
CUD
Pizza
Sandwich
Reimbursable
Served
Specify toppings:
oz.
□ Whole grain-rich
1 sandwich
Meat and Meat Alternates
□
(./)
a::
□
□
□
□
□
□
I
□
□
□
□
I
□
□
□
□
□
□
□
I
□
□
□
□
□
□
□
Reduced-fat
Specify type:
□
oz.
Specify
ingredients:
□
oz.
D Light
Specify flavor(s):
oz.
Trail mix
Yoaurt
--
□ Regular □ Low-fat □ Fat-free
□
□
□
□
□
□
□
2
Cl)
:::::,
Food Description
□ Whole grain-rich
□ Whole grain-rich □ Reduced-fat
1 sandwich
Cheese
C'•
C.
Combination Items and Entrees
Peanut butter & iellv sandwich
G.
·u
Baael
oz.
Whole grain-rich
Specify type:
□
□
Cereal
oz.
Whole grain-rich
Specify type:
□
□
Cookie
oz.
□
□
Corn/tortilla chics
oz.
Whole grain-rich
Specify type:
Whole grain-rich
Specify
type:
Crackers
ea.
Whole grain-rich
Specify type:
Granola bar
oz.
Pretzels
oz.
□
□
□ Whole grain-rich
□
Specify type:
□ Whole grain-rich
□ Soft
□ Hard
□ Salted □ Unsalted
□ Whole grain-rich
□ Whole grain-rich
□ Whole grain-rich
Fruit snacks/fruit leather
fl oz.
Specify flavor(s):
Puddina
Condiments
□ Reg □ Red. fat □ Low-fat
□ Fat-free
□ Reg □ Red. fat □ Low-fat
□ Fat-free
Ranch die
Cream cheese
Ketchuo
3
C'•
·u
0.
a::
□
□
□
Desserts and Other Items
Fruit drink (less than 100% iuice)
G.
('•
Onsite
Sent
OffSite
F.
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
S ft-WI P�C?
0MB Control Number: 0584-XXXX
Expiration Date: XXfXXJXXXX
D
• School Nulrition &
Meal Cost Study- II
SCHOOL NUTRITION AND MEAL COST STUDY-II
CACFP Afterschool Snack and Supper Form (Expanded)
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
Jrvt
m
Ll
Joh
1\
·1--n'\
T &o{
___
School Name: ___
-_-______________________
1. Please indicate the days that CACFP afterschool snacks and/or suppers were prepared
or served during the target week:
�
Monday
□
Tuesday
�
Wednesday
□
Thursday
�
Friday
-
USDA
This page has been left blank for double-sided copying.
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
CACFP Afterschool Snack and Supper Form (Expanded)
Day:
□ Tue
iy"'Mon
□ Wed
□ Thu
A.
□ Fri
Number of Reimbursable Snacks and/or Suppers Served Onsite:
B.
C.
E.
D.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Reimbursable
Prepared/
Available
Reimbursable
Served
Milk
White
Chocolate
Other flavor, Specify:
Other flavor, Specify:
1
fl oz.
fl oz.
F.
:: "0
>< 0
0 0
Onsite
Sent
OffSite
3S-
30
fl oz.
fl oz.
Manufacturer/Brand
Name and Product Code
(If Aoo/icab/e)
Aoolesauce, canned
\ fz_
CUD
Banana, fresh
Fruit cocktail, canned
CUD
-z.,
30
02%
0
01%
02%
0
0 Fat-free/skim
01%
02%
0
□ Fat-free/skim □ 1%
□ 2%
□
□
□ Heavy syrup
0 Extra light syrup
□ Water
..., l!!
g- n
0 a..
...
□
□
0
0
0 Light syrup
0 Juice
0
0
Oranae, fresh
Raisins
B�
01%
ovGnsweetened
" "' j
11
□ Fat-free/skim
fit'Fat-free/skim
□ Sweetened
�i
:!::E
Ill -o
a, U)
Food Description
G.
a:i r..
...,u �
C
Fruit
Aoole, fresh
30
□
oz.
0
Juices
Aoole iuice
fl oz.
Oranae iuice
fl oz.
□ Calcium added
□ Calcium added
Graoe juice
fl oz.
D Calcium added
0
0
□
□
□
□
□
□
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
A.
B.
C.
E.
D.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
F.
('•
0
0
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
LL.
Reimbursable
Served
Manufacturer/Brand
Name and Product Code
(If Aoolicable)
<(
0
Food Description
Veaetables (if offered with a dip or salad dressing, list as a separate item in the condiments section)
Carrots, raw
CUP
Celery, raw
cup
Salad, tossed
cup
French fries
cup
r��W\
�Glt'lJ
Combination Items and Entrees
Burrito
Cheeseburger
Entree salad
'!·JA,<1'()
L3)
'?0
3, '1 oz.
is-
30
1
sandwich
sandwich
Hamburger
sandwich
Macaroni and cheese
Peanut butter & iellv sandwich
�.!Ylot rt.&fo5 '1
oti
z_
�Bean
Chicken
□
D Beef
�heese
--
1
Grilled cheese sandwich
□ Oven-baked □ Deep-fried
canruct I (our Ja-df fm
List dressing as a separate item in
the condiments section
1 salad
1
cup
□ Whole grain-rich
□ Whole grain-rich □ Reduced-fat
1
sandwich
Specify toppings:
Pizza
Sandwich
Spaghetti with sauce
oz.
□ Whole grain-rich
1
sandwich
D Meat sauce D Marinara sauce
cup
□
D Hard shell
Soft tortilla
D Bean
D Beef
D Chicken
D Cheese
Taco
2
G.
(J)
::,
□
□
□
□
□
□
□
□
('•
C.
·c3
a::
□
□
□
□
□
□
□
□
□
□
□
□
D
□
□
□
□
□
□
□
D
□
□
□
□
□
□
D
□
□
□
□
□
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
A.
B.
C.
E.
D.
F.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Off-
Site
Reimbursable
Prepared/
Available
Reimbursable
Served
Meat/Meat Alternates
Cheese
oz.
Chicken nuaaets (breaded)
ea.
Chicken strios (not breaded)
oz.
Peanut butter
oz.
Trail mix
oz.
YoQurt
0
0
Onsite
Sent
LL.
Manufacturer/Brand
Name and Product Code
(If Aoo/icable)
<(
C
Food Description
Specify type:
□
□
oz
□ Reduced-fat
Specify i ngredients:
□ Regular □ Low-fat □ Fat-free
□ Light
Specify flavor(s):
a::
□
□
□
□
□
□
□
□
□
□
Baael
oz.
Wholegrain-rich
Specify type:
□
□
Cereal
oz.
Wholegrain-rich
Specify type:
□
□
Cookie
oz.
Wholegrain-rich
Specify type:
□
□
Corn/tortilla chips
oz.
Wholegrain-rich
Specify type:
□
□
Crackers
ea.
Wholegrain-rich
Specify type:
□
□
Granola bar
oz.
□ Wholegrain-rich
□
3
□
□
□
□
□
Specify type:
·u41
□
Oven-baked
Deep-fried
Weight of each nugget:
Breads and Grains
41
12.
U)
::,
□ Reduced-fat
oz.
G.
C-·
□
□
□
□
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
A.
B.
C.
E.
D.
Number of Portions
Food Item
Pretzels
Portion
Size
(Incl.
Units)
C'•
Reimbursable
Prepared/
Available
Reimbursable
Served
Manufacturer/Brand
Name and Product Code
(If Aoo/icable)
oz.
--
Fruit snacks/fruit leather
0
Food Description
D
D Whole grain-rich
D
D
D Whole grain-rich
D
D
D Whole grain-rich
D
D
D
□
Specify flavor(s):
□ Reg □ Red. fat
D Low-fat
D Fat-free
D Reg D Red. fat D Low-fat
Fat-free
Ranch dio
□
Cream cheese
D
D
D
D
D
D
□
Mavonnaise
D
Italian dressinq
-�(1.l,�
�- ·-- ·· ----
?.\VJ
30
?,,
--
D Fat-free
D Reg D Light D Red. calorie
Fat-free
□
( Oc,l
..rod,Vl-1'\ ,ranVllr/.
D
D
□
D
D
0
D
D
D
D
D
D
D
D
D
D
D
□
4
-
□
D
□ Reg □ Red. fat □ Low-fat
□ Fat-free
D Reg D Light □ Red. calorie
-
D
Ketchup
Mustard
It:
::J
D Whole grain-rich
D Hard
D Soft
D Unsalted
D Salted
fl oz.
Condiments
·c3
<(
- � -L----
Puddinq
Ranch dressinq
C.
LI.
Desserts
Fruit drink (not 100% iuice)
G.
0
Onsite
Sent
OffSite
F.
□
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
A.
C.
B.
D.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
E.
Reimbursable
Prepared/
Available
Reimbursable
Served
Other Menu Items
5
G.
(',
0
0
Onsite
Sent
OffSite
F.
u..
Manufacturer/Brand
Name and Product Code
(If Aoo/icable)
Food Description
<(
·u
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
C
::::,
Q.
0::
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
CACFP Afterschool Snack and Supper Form (Expanded)
Day:
□ Mon
□ Tue
�Wed
□ Thu
A.
□ Fri
Number of Reimbursable Snacks and/or Suppers Served Onsite:
8.
D.
C.
F.
E.
Number of Portions
Food Item
Milk
White
Chocolate
Other flavor, Specify:
Other flavor, Specify:
Portion
Size
(Incl.
Units)
,
fl oz.
fl oz.
�
Reimbursable
Prepared/
Available
�:r
mu.
Reimbursable
Served
Manufacturer/Brand
Name and Product Code
(If Aoo/icable)
Z-1
fl oz.
fl oz.
Fruit
Apple, fresh
Applesauce, canned
\ Vl'll<,(.
CUP
Banana. fresh
Fruit cocktail, canned
cup
"3�
Z-1'
'.'"
�
.:,r, <(
< 0
0 0
Onsite
Sent
OffSite
2q
□ Calcium added
□ Calcium added
□ Calcium added
G.
'; � j
m,,.
f
('•
Q.
'i:i
ct::
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
�
□
□
□
□
□
□
□
□
□
□
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
A.
B.
E.
D.
C.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
0
0
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
ea.
Chicken strips (not breaded)
oz.
Peanut butter
oz.
Trail mix
oz.
Yogurt
oz.
<(
C
□
Reduced-fat
Specify type:
□ Oven-baked
Weight of each nugget:
oz
□ Reduced-fat
Specify ingredients:
-
-
-
-
□ Regular □ Low-fat □ Fat-free
□ Light
Specify flavor(s):
-----
□
□
□
□
□
□
□
□
□
□
□
□ Whole grain-rich
□
□
Cookie
oz.
Whole grain-rich
Specify type:
□
□
Corn/tortilla chips
oz.
Whole grain-rich
Specify type:
□
Crackers
ea.
Specify type:
Granola bar
oz.
□ Whole grain-rich
3
-
□
Whole grain-rich
Specify type:
-
·-
Specify type:
--- - -
Cl)
□
oz.
-
C.
·13
□
□
□
Cereal
-
Cl)
□
□
□
□
Whole grain-rich
Specify type:
oz.
('-
ct:
□
□ Deep-fried
G.
Cl)
::.,
Food Description
(If Ann/icable)
Breads and Grains
Baael
u.
Manufacturer/Brand
Name and Product Code
oz.
Chicken nuoaets (breaded)
C'·
Onsite
Meat/Meat Alternates
Cheese
F.
□
.
□
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
A.
B.
Number of Portions
Portion
Food Item
Pretzels
D.
C.
Size
(Incl.
Units)
E.
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
Manufacturer/Brand
Name and Product Code
(If Aoolicable)
oz.
Food Description
□ Whole grain-rich
□ Soft
□ Hard
□ Salted □ Unsalted
□ Whole grain-rich
□ Whole grain-rich
□ Whole grain-rich
Specify flavor(s):
PuddinQ
Condiments
□ Reg □ Red. fat □ Low-fat
□ Fat-free
□ Reg □ Red. fat □ Low-fat
□ Fat-free
Ranch dip
Cream cheese
Ketchup
Mavonnaise
□ Reg □ Red. fat □ Low-fat
--
Ranch dressinq
4
C'·
C
fl oz.
Italian dressinQ
0
0
<{
Fruit snacks/fruit leather
Mustard
G.
LL
Desserts
Fruit drink (not 100% iuice)
F.
.
·- -
D Fat-free
Reg
Light
Fat-free
Reg
Light
D Fat-free
□
□
□
:::>
a.
'(3
a::
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
-
□
□ Red. calorie
□
□
□ Red.calorie
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
A.
C.
8.
D.
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
E.
Off-
Site
Reimbursable
Prepared/
Available
Reimbursable
Served
Other Menu Items
0
0
Manufacturer/Brand
Name and Product Code
(If Annlicab/e)
u.
�
C
Food Description
=>
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
5
G.
C'·
Onsite
Sent
F.
·u
C.
0::
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
0MB Control Nu mber: 0584-XXXX
Expiration Date: XX/XX/XXXX
D
• School Nutrition &
Meal Cost Study -11
A La Carte Foods Checklist (Expanded)
J=-'o_h_V\_J_(l/l1_r_}Y(__m_1tl_d_lt________
SCHOOL NAME: __
1
COMPLETE ON: [insert sticker with day of week]
DATE COMPLETED:
1..D_1l_111_Q_1__fe_1112...1_Q_1 i.1_Q1
Day
Year
Month
Note: Please refer to the Instructions for the Menu Survey for instructions on completing this form.
USDA
A LA CARTE FOODS CHECKLIST (EXPANDED)
SCHOOL NUTRITION AND MEAL COST STUDY-II
A La Carte Foods Checklist (Expanded)
A.
Food Item
C.
Lunch
Milk
1.
Whole white milk
1
□
1D
2.
Reduced fat (2%) white milk
2D
2D
3.
Low-fat (1% or 0.5%) white milk
3'�
3
4.
Fat-free/skim white milk
4
5.
Reduced fat (2%) flavored milk
50
50
6.
Low-fat (1% or 0.5%) flavored milk
s□
s□
7,
Fat-free/skim flavored milk
7
7
8,
Other milk beverages, including non-dairy milks (Specify)
✓
4
llY"
✓
8.10
8.1 0
b.
8.2
□
8,2 0
C.
8.3 0
8.3 0
d.
8.4
□
8.5 □
100% Juice and Water
1.
Juice (100% fruit or vegetable juice)
1
2.
Bottled water (plain, flavored, or sparkling)
2
Beverages Other than Milk, 100% Juice, or Water
1.
rg/
if
a.
e.
B.
Breakfast
,£
✓
8.4
□
8.50
v6
di'
2
Diet carbonated soft drink (diet soda/pop)
1D
1D
2.
Regular carbonated soft drink (regular soda/pop)
2D
20
3.
Juice drinks and other sweetened drinks (such as cranberry drink, Hi-C,
lemonade, fruit punch, iced tea)
30
30
4.
Sports drinks (such as Gatorade or PowerAde)
4D
4
5.
Energy drinks (such as Red Bull or Monster Energy)
s
□
50
6.
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)
s0
60
7.
Hot or cold coffee or tea
7
0
70
8.
Other beverages (Specify)
□
✓
0
a.
8.1
b.
8.2 0
8.20
C.
8.30
8.30
d.
8.40
8.40
e.
8.5 0
8.5
8.1
□
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
D.
E.
Fruit
Breakfast
Lunch
I
1.
Dried fruit (such as raisins or apricots)
1
□
2.
Canned or frozen fruit
2
E(
□
20'
3
GI/"
3
1. Baked French fries (including tater tots and sweet potato fries)
1
□
1�
2. Deep-fried French fries (including tater tots)
20
2□
3. Potatoes or sweet potatoes (other than French fries/tater tots/sweet potato fries)
a
□
30
4. Corn
40
40
5. Carrots
50
50
6. Broccoli
60
6
7. Peas
70
70
8. Green beans
aO
aO
9. Mixed vegetables
90
9
3. Fresh fruit
Vegetables
1
Ef"
COOKED
✓
ref'
10. Vegetable soup
10 0
10 0
11. Beans/legumes (such as baked beans, black beans, or pinto beans)
110
11
✓
12. Other cooked vegetables (Specify)
a.
12.10
12.10
b.
12.2 0
12.20
C.
12.3 0
12.3 0
d.
12.40
12.40
e.
12.5 0
12.5 0
RAW (NOT COOKED)
✓
13. Carrot sticks
130
13
14. Celery
14 0
140
15. Cucumbers
150
150
16. Salad bars
16 0
160
17. Tossed salads (side)
17 0
17�
18. Prepared vegetable salads (such as potato salad, coleslaw, or three bean salad)
18 0
180
19. Other raw vegetables (Specify)
a.
19.1 0
19.1 0
b.
20.20
20.20
C.
21.30
21.30
2
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
F.
G.
Breakfast
Lunch
d.
22.4 0
22.4 0
e.
23.5 0
23.5 0
Breads and Grains
1.
Whole grain-rich breads, rolls, bagels, or tortillas
1r/
10
2.
Regular (not whole grain-rich) bread, rolls, bagels, or tortillas
20
20
3.
Other bread items (such as breadsticks, biscuits, croissants, or hot pretzels)
30
30
4.
Low-fat muffins
40
40
5.
Regular muffins (not lower in fat)
5
6.
Ready-to-eat breakfast cereal
6
7.
Pancakes, waffles, or French toast
1ef
70
8.
Rice, pasta, or cooked cereal
a0
a0
9.
Other bread/grains (Specify)
a.
9.1 0
9.1 0
b.
9.20
9.20
C.
9.3 0
9.3 0
d.
9.4 0
9.40
e.
9. 5 0
9.5 0
r(
✓
50
60
Meats or Meat Alternates
1. Breaded chicken/turkey (nuggets, patties, strips, parts)
10
11�
2. Not breaded chicken/turkey (nuggets, patties, strips, parts)
20
20
3. Breaded beef/pork (nuggets, patties, strips)
30
30
4. Not breaded beef/pork (nuggets, patties, strips)
40
4
5. Sausage or bacon
5
50
6. Breaded fish (nuggets, patties, strips/sticks)
60
sO
7. Not breaded fish (nuggets, patties, strips/sticks, fillets)
70
70
8. Eggs
aef
a0
9. Cheese (including string cheese)
90
90
10. Fried or baked cheese or pizza sticks (for example, Bosco sticks)
10 0
10 0
11. Chili
11 0
110
12. Yogurt
120
120
13. Peanut butter or other nut or seed butter
13 0
130
14. Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)
14 0
14 0
3
✓
✓
A LA CARTE FOODS CHECKLIST (EXPANDED)
Breakfast
Food Item
Lunch
15. Other meats/meat alternates (Specify)
H.
a.
15.10
15.10
b.
15,2 0
15.20
C.
15.30
15.30
d.
15,40
15.4 0
e.
15.50
15.5 0
1. Cheeseburger or hamburger
10
10
2. Hot dog or corn dog
20
20
3. Barbecue sandwich (including sloppy joes)
30
30
4. Peanut butter or other nut or seed butter sandwich (including with jelly)
40
4�
5. Cheese sandwich
50
5�
6. Veggie burger
60
60
7, Chicken, egg, or tuna salad sandwich
70
70
a0
a0
90
90
Entrees
SANDWICHES
8,
Sandwich with breaded meat, poultry or fish
9. Sandwich with cold cuts (salami, bologna, or pepperoni)
10. Sandwich with plain (not breaded) meat, poultry or fish
100
11. Breakfast sandwich or breakfast burrito
11
0
11
12.1
0
12.1
b.
12.2
0
12,2
C.
12.3
0
12.3 0
d.
12.4
0
12.4
0
e.
12.5
0
12.5
0
13. Pizza without meat
13
0
13
14. Pizza with meat
14
□
14 �
15. Calzone or Hot Pocket
15
0
15
16. Burritos
16
0
16
17. Other Mexican foods (such as tacos, nachos, or quesadillas)
17
□
17
0
18. Chinese food
18 0
18
0
19
□
10�
12. Other sandwiches (Specify)
a.
1._\ IO VIIJtA
�1 oe
OTHER ENTREES
□
20 □
19. Lasagna
19
20. Spaghetti
4
D
✓
0
if'
0
✓
20�
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
Breakfast
Lunch
21. Macaroni and cheese
21 0
21 0
22. Entree salad (such as chefs, cobb, taco, or chicken Caesar)
220
22�
23
230
230
a.
24.1 0
24.1 0
b.
24.20
24.2 0
C.
24.30
24.30
d.
24.40
24.40
24.50
24.5 0
1. Low-fat/reduced-fat cakes, cupcakes, or brownies
10
10
2. Regular cakes, cupcakes, or brownies (not lower in fat)
20
2 [{)/'
3. Low-fat pies, turnovers, or toaster pastries
30
30
4. Regular pies, turnovers, or toaster pastries (not lower in fat)
40
40
5. Low-fat doughnuts or cinnamon rolls
50
50
6. Regular doughnuts or cinnamon rolls (not lower in fat)
6
7. Low-fat cookies
70
70
8. Regular cookies (not lower in fat)
e0
8
9. Fruit crisp or cobbler
sO
sO
a.
10.1 0
10.10
b.
10.20
10.20
C.
10.30
10.3 0
d.
10.40
10.4 0
10.5 0
10.5 0
Soup with meat or beans (such as chicken, clam chowder, or minestrone)
24. Other entrees (Specify)
I.
e.
Baked Goods and Desserts
ig/
60
ef
10. other baked goods/desserts (Specify)
J.
e.
Frozen and Dairy Desserts
1.
Frozen fruit bars or popsicles
10
10
2.
Milkshakes, smoothies, or yogurt drinks
20
20
3.
Low-fat/reduced-fat ice cream, novelties, frozen yogurt, or sherbet
30
30
4.
Regular ice cream, novelties, frozen yogurt, or sherbet
40
40
5.
Pudding
s0
s0
5
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
6.
Breakfast
Lunch
Other frozen/dairy dessert (Specify)
a.
6.1 0
6.10
b.
6.20
6.2 0
C.
6.30
6.30
d.
6.40
6.40
e.
6.5 0
s.5 0
10
10
2. Regular chips (not lower in fat; such as corn, potato, puffed cheese, tortilla, or
snack mixes)
20
2
3. Hard pretzels
30
30
4. Popcorn
40
4
5. Cracker sandwiches with cheese or peanut butter
sO
50
6. Other types of crackers (including animal crackers)
sO
sO
7. Low-faUreduced-fat granola bars, cereal bars, or energy bars
d6,,
70
8. Regular granola bars, cereal bars, or energy bars (not lower in fat)
a
aO
9. Crispy rice bars or treats
90
90
10. Candy or gum
100
10 0
11. Fruit snacks (such as Fruit Roll-Ups or fruit leather)
11 0
11 0
12. Meat snacks (such as jerky or pork rinds)
12 0
12 0
a.
13.1 0
13_1 0
b.
13.20
13_20
b.
13.30
13.30
b.
13.40
13.40
b.
13.5 0
13.5 0
a.
1.10
1.1 0
b.
1.20
1.20
C.
1.30
1_30
d.
1.40
1.4 0
e.
1.s 0
1.50
K.
Snacks
1. Low-faUreduced-faUbaked chips (such as corn, potato, puffed cheese, tortilla, or
snack mixes)
13.
L.
l'1
✓
✓
Other snacks (Specify)
Other A La Carte Items (Specify)
6
NON-REIMBURSABLE FOODS FORM (EXPANDED)
Non-Reimbursable Foods Form (Expanded)
0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
NOTES:
•
•
•
•
For instructions on completing this form, please refer to Instructions for the Menu Survey.
Use this form to report foods that are sold solely on a non-reimbursable or a la carte basis and not available as part of a reimbursable meal or snack.
Include ONLY non-reimbursable foods that are supplied or stocked by foodservice.
For each food, record information on the number of portions either each day (in Column F) or as a total at the end of the week (in Column G).
School Name:
Jo\ll V\ Swt It n
Where Offered:·B"'serving line breakfast
A.
B.
C.
m
r d.d Ce
Cil/Serving line lunch
□
✓sreakfast
Meal:
Snack bar
E.
D.
Q)
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in
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Q)
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Size
Food Name
Oto ca lttK
Coo\tZts
0V(1
(Include
Units)
P
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0
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□
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□
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Manufacturer/
Brand Name and
Product Code
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0
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& 0
0
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D
)�
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Weekly Total Number
of Portions
Friday
z
:i::
iii
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0
....C:
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a,
0
.E
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□
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OJ
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-
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Q)
�
NON-REIMBURSABLE FOODS INVENTORY (EXPANDED)
Non-Reimbursable Foods Inventory (Expanded)
0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
NOTES:
•
•
•
•
,J�o�n-n�S�m_i�_�m�_r d����---
SchoolName:__
Where Offered: ifserving line breakfast
A.
�erving line lunch
w
:W]
ti:::,
ro a>
ll.. "o
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u
Gvt o U> \ cu-e Cvi� () Cot>�- es
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CV\lc
'iii
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Q)
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Q)
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0
0
:I=
�o
-0
Q)
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'C
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Q)
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:i::
0
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-0
Q)
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0:::
Q)
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Q)
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0
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7
0
0
0
I
0
0
0
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0
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Friday
Thursday
>
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lnventorv
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>
MENU SURVEY SCREENER – EXPANDED (GROUP 3)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Menu Survey Screener Questions (Expanded)
Note: The Menu Survey screener questions will be administered prior to the target week to identify which
Menu Survey forms are relevant to a school based on its food service program. Technical assistants
(TAs) will administer the questions over the phone with school nutrition managers (SNMs) and record the
responses in the Electronic Menu Survey (EMS). The EMS will then display the relevant forms on each
school’s task list.
This page has been left blank for double-sided copying.
MENU SURVEY SCREENER QUESTIONS (EXPANDED)
1.
Does your school participate in the School Breakfast Program (SBP)?
1
0
□
□
Yes
No
2.
Does your school provide reimbursable snacks or suppers for one or more afterschool
programs (either at this school or another location)?
2a.
School provides afterschool snacks through the National School Lunch Program (NSLP).
1
0
2b.
0
No
□
□
Yes
No
School provides afterschool suppers through the CACFP.
1
0
3.
Yes
School provides afterschool snacks through the Child and Adult Care Food Program
(CACFP).
1
2c.
□
□
□
□
Yes
No
Does your school’s food service department sell any foods or beverages outside of
reimbursable meals? This may include foods or beverages that are offered as part of
reimbursable meals but also sold on an a la carte basis, as well as foods and beverages that
are sold only outside of reimbursable meals.
1
0
□
□
Yes
No
[If no, skip to Q6]
[If Q3 = Yes]:
4.
In what locations does your school’s food service department sell foods or beverages
outside of reimbursable meals?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
□
□
□
□
□
□
□
[If Q1 = Yes] A la carte serving lines at breakfast
A la carte serving lines at lunch
Snack bars
Vending machines
Food carts
School stores
Other, Specify: ______________________________
1
MENU SURVEY SCREENER QUESTIONS (EXPANDED)
QUESTION 5 and 6: ASK ONLY FOR GROUP 3 SCHOOLS
[If Q3 = Yes]
5a.
Does your school’s food service department sell any foods or beverages that are never
offered as part of a reimbursable meal?
□
□
1
0
Yes
No
[If Q5a = Yes]
5b.
For foods or beverages that are sold by your school’s food service department and never
offered as part of a reimbursable meal, would you be able to report how many portions were
sold either each day or over the course of a week?
□
□
1
0
Yes
No
[If Q5b = Yes]
5c.
Would you prefer to report the number portions of each non-reimbursable foods sold on a
daily basis or as total across the week?
1
0
□
□
Daily basis
Weekly basis
[If Q5b = No]
5d. For foods or beverages that are sold by your school’s food service department and never
offered as part of a reimbursable meal, would you be able to track an inventory of how many
were sold over the course of the week? That is, you would record your starting inventory on
Monday of your target week, any deliveries received during the week, and then your ending
inventory on Friday.
1
0
6.
□
□
Yes
No
Does your school’s food service department prepare foods or meals that are sent or shipped
to another location, school, or facility?
1
0
□
□
Yes
No
2
MENU SURVEY SCREENER QUESTIONS (EXPANDED)
[If Q6 = Yes]
6a. Which of the following types of foods or meals are sent off-site? (Mark all that apply)
1
2
3
4
5
6
7.
□
□
□
□
□
□
Reimbursable breakfasts
Reimbursable lunches
Afterschool snacks provided through the NSLP [If Q2a = Yes]
Afterschool snacks or suppers provided through the CACFP [If Q2b or Q2c = Yes]
Non-reimbursable foods (that is, foods or beverages that are not offered as part of
reimbursable meals or snacks)
Other
_________________________________
Is it correct that your school serves students in grades [Y to Z]?
[Y = lowest grade and Z = highest grade, as reported in SFA Director Planning Interview]
1
0
□
□
Yes
No
[If Q7 = No]
7a. What grades does your school serve?
[drop-down lists with values for: pre-kindergarten, kindergarten, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12]
SELECT ONE
Lowest grade: ___________
SELECT ONE
Highest grade: ___________
[Note: The EMS will compute the standard grade group(s) (used in the NSLP/SBP nutrition standards)
that are included in the school, based on the reported grade span of the school:
a. K-5 only
b. 6-8 only
c. 9-12 only
d. K-5 and 6-8
e. K-5 and 9-12
f. 6-8 and 9-12
g. K-5, 6-8, and 9-12
If the school includes grade span combinations d, e, f, or g, the SNM will answer additional questions
when completing the Reimbursable Foods Form in the Electronic Menu Survey. See the instrument
named “Menu Survey Enhancements Administered through the Electronic Menu Survey” for more
details.]
3
This page has been left blank for double-sided copying.
DAILY MEAL COUNTS FORM (GROUP 3)
This page has been left blank for double-sided copying.
OMB Controll Number: 0584-xxxx
Expiration Date: xx/xx/xxxx
Daily Meal Counts Form (Expanded)
School Name:
Date:
Instructions:
1.
2.
In the boxes for the Number of Reimbursable NSLP Lunches Served and Number of Reimbursable SBP Breakfasts Served, please
record the number of free, reduced-price, and full-price reimbursable meals served in your school each day of the target week. Do not
include meals for which you do not claim reimbursement, for example, second lunches sold to students on an a la carte basis. If your school
provides free meals to all students, record the number of meals served in the “free” column.
Check the box if the number of reimbursable meals served on a day was much higher or lower than usual, and describe the reason for this
difference in the space provided.
Number of Reimbursable NSLP Lunches Served
Free
ReducedPrice
FullPrice
FOR OFFICE
USE ONLY
Please check if the number of reimbursable lunches
served this day was much higher or lower than usual.
Monday
→ Reason:
_________________________________
Tuesday
→ Reason:
_________________________________
Wednesday
→ Reason:
_________________________________
Thursday
→ Reason:
_________________________________
Friday
→ Reason:
_________________________________
Number of Reimbursable SBP Breakfasts Served
Free
ReducedPrice
FullPrice
FOR OFFICE
USE ONLY
Please check if the number of reimbursable breakfasts
served this day was much higher or lower than usual.
Monday
Tuesday
→ Reason:
→ Reason:
Wednesday
→ Reason:
_________________________________
Thursday
→ Reason:
_________________________________
Friday
→ Reason:
_________________________________
_________________________________
_________________________________
Instructions:
1.
Please record the total value of your non-reimbursable food sales by venue, including all student, adult, and other sales in venues operated or
stocked by the food service department. If you do not keep venue-specific records, you may simply enter the total sales across all venues into
the last column (named “Total Across All Venues”). You can either record the sales each day of the target week or enter it as a total across the
week in the last row (named “Weekly Total”).
Total Non-Reimbursable Food Sales in Venues Operated or Stocked by the Food Service Department
Serving Line
(A la Carte)
Snack Bar
Vending
Machine
Food Cart
School Store
Other:
__________
Total Across
All Venues
Monday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Tuesday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Wednesday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Thursday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Friday
$_________
$_________
$_________
$_________
$_________
$_________
$_________
Weekly Total $_________
$_________
$_________
$_________
$_________
$_________
$_________
1
This page has been left blank for double-sided copying.
REIMBURSABLE FOODS FORM BREAKFAST (GROUP 3)
This page has been left blank for double-sided copying.
Reimbursable Meal Counts
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
How many reimbursable breakfasts did you plan to serve at your school
this day?
How many reimbursable breakfasts did you serve at your school this
day?
SCHOOL NUTRITION AND MEAL COST STUDY-II
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
B.
C.
Day:
Mon
Tue
Wed
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over for
Later
Use
Wasted
Thu
Fri
F.
G.
Check Box if
Prepared from a
Recipe
A.
Date:______________________________
Check Box if
USDA Food
School Name:__________________________________________
MILK
White, fat-free/skim
fl oz.
White, 1%
fl oz.
White, 2%
fl oz.
White, whole
fl oz.
Chocolate, fat-free/skim
fl oz.
Chocolate, 1%
fl oz.
Chocolate, 2%
fl oz.
Other flavor
Specify: __________________
fl oz.
Other flavor
Specify: __________________
fl oz.
Other flavor
Specify: __________________
fl oz.
fl oz.
fl oz.
1
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over for
Later
Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, complete a RECIPE FORM.)
Apple, fresh
Applesauce, canned
Apricots, canned
cup
Sweetened
Unsweetened
Heavy syrup
Light syrup
Extra light syrup Juice Water
cup
Sweetened
cup
Heavy syrup
Fruit cocktail, canned
cup
Grapes, fresh
cup
Unsweetened
Light syrup
Extra light syrup Juice Water
Heavy syrup
Light syrup
Extra light syrup Juice Water
cup
Heavy syrup
Light syrup
Extra light syrup Juice Water
cup
Pears, fresh
Heavy syrup
Pears, canned
Orange, fresh
Peaches, canned
Kiwi, raw
Mandarin oranges, canned
Banana, fresh
Blueberries, frozen
cup
Heavy syrup
Pineapple, canned
cup
Raisins
oz.
Light syrup
Extra light syrup Juice Water
Light syrup
Extra light syrup Juice Water
2
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over for
Later
Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and/or vegetable juice. List fruit drinks (not 100% juice) in the “Other Menu Items” section.)
Apple juice
fl oz.
Calcium added
Grape juice
fl oz.
Calcium added
Orange juice
fl oz.
Calcium added
Fruit juice blend
fl oz.
Calcium added
BREADS AND GRAINS (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item. For example, toast w/ cereal).
Apple Jacks
oz.
Cheerios, plain
oz.
Cheerios, Apple Cinnamon
oz.
Cheerios, Fruity
oz.
Cheerios, Honey Nut
oz.
Cinnamon Toast Crunch
oz.
Cocoa Krispies
oz.
Cocoa Puffs
oz.
Froot Loops
oz.
Frosted Flakes
oz.
Frosted Mini Wheats
oz.
Golden Grahams
oz.
Granola
oz
Kix
oz.
Lucky Charms
oz.
Marshmallow Mateys
oz
Raisin Bran
oz.
Rice Chex
oz
Rice Krispies
oz.
Trix
oz.
Reg Low-fat
3
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over for
Later
Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
B.
Check Box if
USDA Food
A.
HOT CEREALS (Note: If prepared with fat and/or milk, complete a RECIPE FORM)
Cream of Wheat
cup
Instant
Quick
Reg
Grits
cup
Instant
Quick
Reg
Oatmeal
cup
Instant
Quick
Reg
OTHER BREADS AND GRAINS OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item. For example, toast
w/ cereal, or biscuit w/ sausage).
Specify type: ___________________
Bagel
oz.
Biscuit
oz.
Danish or turnover
oz.
Fruit
Cheese
Doughnut
oz.
Icing/glaze
No Icing/glaze
English muffin, plain
oz.
English muffin, buttered
oz.
Margarine
Granola/cereal bar
oz.
Specify type: ___________________
Muffin
oz.
Specify type: ___________________
Pancake
oz.
Roll, cinnamon
oz.
Icing
Toast, plain
oz.
Specify type: ___________________
Specify type: ___________________
Toast, buttered
oz.
Toaster pastry
oz.
Butter
No Icing
Margarine
4
Fruit
Chocolate chip
Other:____________
oz.
Butter
Low-fat
Plain
Waffles
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over for
Later
Use
Wasted
Plain Fruit Chocolate chip
Other:____________
Waffle sticks
F.
G.
Check Box if
Prepared from a
Recipe
B.
Check Box if
USDA Food
A.
Weight of each stick:_________oz.
ea.
MEATS AND MEAT ALTERNATES OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item. For example, sausage with
biscuit, or yogurt with cereal).
Bacon
Pork
sl
Turkey
Eggs
cup
Scrambled Hard boiled
Fried
Ham
oz.
Pork
Peanut butter
oz.
Reduced-fat
Sausage
oz.
Beef or pork Chicken or turkey
Turkey
Reg Low-fat Fat-free Light
Yogurt
Specify flavors: _________________
oz.
COMBINATION ITEMS
Breakfast burrito
Eggs Cheese Beans Potato
Other:_______________
oz.
Cheese
Egg sandwich
1
sandwich
Cheese
Egg sandwich
Sausage
Ham
Bacon
Other:____________
Specify bread type: ______________
Sausage
Ham
Bacon
Other:____________
Specify bread type: ______________
1
sandwich
French toast
French toast sticks
Grilled cheese
ea.
1
sandwich
5
Weight of each stick:_________oz.
Reduced-fat
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over for
Later
Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
Pancake on a stick
oz.
Beef or pork Chicken or turkey
Pizza
oz.
Reduced-fat
Specify toppings: _______________
CONDIMENTS
Self-serve condiments or fixins’
bar
1
serving
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
Butter
Reg
Red. fat
Light Fat-free
Reg
Red. fat
Low-fat Fat-free
Cream cheese
Gravy
Honey
Sugar-free
Jelly
Ketchup
Margarine
Salsa
Syrup
6
Low sodium
Sugar-free
REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left
Over for
Later
Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
B.
Check Box if
USDA Food
A.
OTHER MENU ITEMS
7
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REIMBURSABLE FOODS FORM:
LUNCH (GROUP 3)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Reimbursable Meal Counts
SCHOOL NUTRITION AND MEAL COST STUDY-II
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
How many reimbursable lunches did you plan to serve at your school this
day?
How many reimbursable lunches did you serve at your school this day?
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
A.
B.
Day:
C.
Mon
Tue
Wed
Thu
D.
E.
F.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Food Item
Check Box if
USDA Food
Number of Portions
Portion
Size
(Include
Units)
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Fri
G.
Check Box if
Prepared from a
Recipe
School Name:___________________________________________ Date:______________________________
MILK
White, fat-free/skim
fl oz.
White, 1%
fl oz.
White, 2%
fl oz.
White, whole
fl oz.
Chocolate, fat-free/skim
fl oz.
Chocolate, 1%
fl oz.
Chocolate, 2%
fl oz.
Other flavor
Specify: ____________________
fl oz.
Other flavor
Specify: ____________________
fl oz.
Other flavor
Specify: ____________________
fl oz.
fl oz.
fl oz.
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, complete a RECIPE FORM.)
Apple, fresh
Applesauce, canned
Apricots, canned
cup
Sweetened
Unsweetened
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Banana, fresh
cup
Sweetened
Unsweetened
Fruit cocktail, canned
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Grapes, fresh
cup
Blueberries, frozen
Kiwi, raw
Mandarin oranges, canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
cup
Orange, fresh
Peaches, canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
cup
Pears, fresh
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Pineapple, canned
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Raisins
oz.
Pears, canned
2
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and/or vegetable juice. Fruit drinks that are not 100% juice should be entered in the “Desserts, Drinks, and Snacks” section.)
Apple juice
fl oz.
Calcium added
Grape juice
fl oz.
Calcium added
Orange juice
fl oz.
Calcium added
Fruit juice blend
fl oz.
Calcium added
Frozen juice cup/bar
fl oz.
Specify flavor: ______________
fl oz.
VEGETABLES (Note: If beans or peas are being counted as a meat alternate and not a vegetable choice, enter them in the “Other Entrees and Meat/Meat Alternates” section.)
cup
Vegetarian
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_______________________
Broccoli, cooked
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
________________________
Broccoli, raw
cup
Baked beans
Beans, green
Carrots, cooked
cup
Carrots, raw
cup
Cauliflower, raw
cup
Celery, raw
cup
Corn, kernels
cup
Cucumber, raw
cup
With pork
If offered, list dip as separate item(s) or complete a RECIPE FORM
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
If offered, list dip as separate item(s) or complete a RECIPE FORM
If offered, list dip as separate item(s) or complete a RECIPE FORM
If offered, list dip as separate item(s) or complete a RECIPE FORM
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
If offered, list dip as separate item(s) or complete a RECIPE FORM
3
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
French fries
cup
Lettuce and tomato
cup
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Manufacturer/Brand Name
and Product Code
(If Applicable)
F.
Food Description
Oven-baked
Deep-fried
G.
Check Box if
Prepared from a
Recipe
A.
cup
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Peas, green
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Potatoes, whipped or mashed
cup
From fresh
Refried beans
cup
From dry Canned
Low sodium
Fat added, specify type:
_________________________
Red peppers, raw
cup
If offered, list dip as separate item(s) or complete a RECIPE FORM
Green peppers, raw
cup
If offered, list dip as separate item(s) or complete a RECIPE FORM
Mixed vegetables
Sweet potatoes
cup
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Sweet potato fries or tots
cup
Oven-baked
Side salad bar
(non-entrée or small portion)
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Salad, tossed
cup
Tater tots or shapes
cup
Tomato, raw
cup
Deep-fried
List dressing and any bread/grain items offered with the tossed salad
as separate item(s)
Oven-baked
Deep-fried
If offered, list dip as separate item(s) or complete a RECIPE FORM
4
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
SANDWICHES (Note: In Column A, indicate whether any items in this section were offered only with another particular food item. For example, a peanut butter sandwich with a cheese stick, or a grilled cheese sandwich with a yogurt.)
Cheeseburger
1
sandwich
Chicken filet or breast (not breaded)
1
sandwich
Chicken patty (breaded)
1
sandwich
Fish sandwich
1
sandwich
Grilled cheese
1
sandwich
Ham and cheese
1
sandwich
Hamburger
1
sandwich
Hot dog
1
sandwich
Italian sub
1
sandwich
Peanut butter & jelly
1
sandwich
Rib, barbeque
1
sandwich
Sloppy joe
1
sandwich
Turkey
1
sandwich
Tuna salad
1
sandwich
Veggie burger
1
sandwich
1
sandwich
1
sandwich
1
sandwich
1
sandwich
Breaded
Beef or pork
Chicken or turkey
Beef Pork
Chicken or turkey
5
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
1
sandwich
1
sandwich
ENTRÉE SALADS (Note: List dressing and any bread/grain items offered with an entrée salad as separate item(s). Also, add a note in Column A if a particular bread/grain item is offered only with a particular entrée salad.)
Chef's salad
1 salad
Chicken Caesar salad
1 salad
Taco salad
1 salad
1 salad
1 salad
1 salad
1 salad
1 salad
1 salad
SELF-SERVE/MADE-TO-ORDER ENTRÉE BARS
Entrée salad bar
1 serving
Potato bar
1 serving
Nacho/taco bar
1 serving
Sandwich/deli bar
1 serving
Pasta/Italian bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
6
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
OTHER ENTREES AND MEAT/MEAT ALTERNATES (Note: In Column A, indicate whether any items in this section were offered only with another particular food item. For example, a cheese stick with a peanut butter sandwich, a yogurt with a grilled cheese
sandwich, or chicken nuggets with a roll).
cup
From dry
Canned
Low sodium Fat added, specify type:
_______________
Burrito
oz.
Bean
Chicken
Cheese (string cheese or cubes)
oz.
Reduced-fat
oz.
Reduced-fat
Specify fillings:
________________________
Chicken nuggets (breaded)
ea.
Oven-baked Deep-fried
Weight of each
nugget:_____________oz.
Chicken strips (not breaded)
oz.
Chicken patty (not sandwich)
oz.
Beans or peas
(Specify type) ________________
Cheese breadstick or pizza stick
Beef
Cheese
Chicken piece(s)
(Specify part)_________________
Oven-baked
Deep-fried
Breaded
Oven-baked
With skin
Deep-fried
oz.
Beef or pork
Chicken or turkey
ea.
Meatless Beef or pork
Chicken or turkey
Weight of each egg roll:__________oz.
Fish sticks or nuggets
ea.
Oven-baked Deep-fried
Breaded
Weight of each
nugget/stick:__________oz.
Macaroni and cheese
cup
Nachos
oz.
Peanut butter
oz.
Corndog
Egg rolls
Pizza, cheese
oz.
Pizza, pepperoni
oz.
Reduced-fat
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
7
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
F.
Food Item
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Pizza, vegetarian
oz.
Food Description
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
Specify toppings:____________
Pizza pocket
oz.
Reduced-fat
Specify filling:_______________
Stir fry with rice or noodles
cup
Spaghetti with sauce
cup
Pizza, sausage
oz.
Wasted
Manufacturer/Brand Name
and Product Code
(If Applicable)
Meat sauce
Marinara sauce
Hard shell Soft tortilla
Bean
Beef
Chicken
Cheese
Specify type: Regular Greek (high
protein)
Specify fat: Whole Low-fat
Taco
G.
Check Box if
Prepared from a
Recipe
A.
Fat-free Light
Yogurt
Specify flavors: _________________
oz.
BREADS AND GRAINS OFFERED SEPARATELY (Note: In Column A, indicate wheter any items in this section were offered only with a particular entrée or meat/meat alternate. For example, crackers with Chef’s salad or a roll with chicken nuggets.)
Biscuit
oz.
Reduced-fat
Bread, plain
oz.
Specify type:_______________
Bread, buttered
oz.
Specify type:_______________
Margarine
Butter
Breadstick
oz.
Specify type:_______________
Cornbread
oz.
Corn/tortilla chips
oz.
Specify type:_______________
Crackers
ea.
Croutons
oz.
Rice
cup
White
Roll
oz.
Specify type:_______________
8
Brown
Wild
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Food Item
Pasta
Pretzels
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
cup
Soft
Salted
oz.
Hard
Unsalted
DESSERTS, DRINKS, AND SNACKS OFFERED AS PART OF A REIMBURSABLE MEAL
Brownie
Icing
Cake
Specify type: _______________
Specify type: _______________
Specify type: _______________
fl oz.
Specify type: _______________
Fruit turnover
oz.
Specify type: _______________
Gelatin
cup
With fruit
With whipped topping
Potato chips
oz.
Reduced-fat
Cookie
oz.
Fruit crisp or cobbler
Fruit drink (not 100% juice)
Baked
SALAD DRESSINGS
Caesar dressing
Reg Light Red. calorie
Fat-free
French dressing
Reg Light Red. calorie
Fat-free
Honey mustard dressing
Reg Light Red. calorie
Fat-free
Italian dressing
Reg Light Red. calorie
Fat-free
Ranch dressing
Reg Light Red. calorie
Fat-free
9
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Manufacturer/Brand Name
and Product Code
(If Applicable)
F.
Food Description
Reg Light Red. calorie
Fat-free
Reg Light Red. calorie
Fat-free
G.
Check Box if
Prepared from a
Recipe
A.
CONDIMENTS
Self-serve condiments or fixins’ bar
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
1 serving
Barbeque sauce
Butter
Cream cheese
Reg Red. fat Low-fat
Fat-free
Gravy
Reg Red. fat Low-fat
Fat-free
Honey
Hot sauce
Jalapeno peppers
Sugar-free
Jelly
Ketchup
Margarine
Reg Red. fat Low-fat
Fat-free
Mayonnaise
Mustard
Pickles, slices
Reg Red. fat Low-fat
Fat-free
Ranch dip
Relish
Salsa
Low sodium
Sour cream
Reg Red. fat Low-fat
Fat-free
Syrup
Sugar-free
Tartar sauce
Reg Red. fat Low-fat
Fat-free
10
REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)
B.
C.
D.
E.
Manufacturer/Brand Name
and Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Check Box if
USDA Food
Number of Portions
Onsite
Total
Prepared
Sent
Off-Site
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared from a
Recipe
A.
OTHER MENU ITEMS
11
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RECIPE FORM – EXPANDED (GROUP 3)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Recipe Form (Expanded)
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School
Name:
Recipe/Food Name:
Breakfast
Day:
1
Mon
6
All
2
2
Tue
Lunch
3
3
Wed
Outside of Meal Periods
4
Thu
5
Fri
Size of One Serving (include units):
Number of Servings Prepared:
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
Ingredient Description
1
E.
F.
Check Box if
Prepared
from a ecipe
1
Check Box if
USDA Food
Meal:
This page has been left blank for double-sided copying.
SELF-SERVE/MADE-TO-ORDER BAR FORM - EXPANDED (GROUP 3)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Self-Serve/Made-to-Order Bar Form (Expanded)
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
1
Breakfast
A.
Food Name
2
Lunch
Day:
1
All
2
Mon
3
Tue
4
Wed
B.
C.
D.
Portion Size,
If
Pre-portioned
(Include units)
Manufacturer/
Brand Name and
Product Code (if
applicable)
Food Description
1
5
Thu
6
Fri
E.
F.
Check Box if
Prepared from
a Recipe
Meal:
Name of Bar:
Check Box if
USDA Food
School
Name:
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NSLP AFTERSCHOOL SNACK FORM - EXPANDED (GROUP 3)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
SCHOOL NUTRITION AND MEAL COST STUDY-II
NSLP Afterschool Snack Form (Expanded)
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name: __________________________________________________________________
1. Please indicate the days that NSLP afterschool snacks were prepared or served during
the target week:
□
□
□
□
□
Monday
Tuesday
Wednesday
Thursday
Friday
This page has been left blank for double-sided copying.
NSLP Afterschool Snack Form (Expanded)
Tue
Wed
A.
Thu
Fri
B.
Number of Reimbursable Snacks Served Onsite: _________
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
F.
G.
Check Box if
Prepared from
a Recipe
Mon
Check Box if
USDA Food
Day:
Milk
fl oz.
Fat-free/skim
1%
2%
Chocolate
fl oz.
Fat-free/skim
1%
2%
Other flavor, Specify: ____________________
fl oz.
Fat-free/skim
1%
2%
Other flavor, Specify: ____________________
fl oz.
Fat-free/skim
1%
2%
White
Fruit
Apple, fresh
Applesauce, canned
Sweetened
cup
Unsweetened
Banana, fresh
Fruit cocktail, canned
Heavy syrup
Extra light syrup
Water
cup
Light syrup
Juice
Orange, fresh
Raisins
oz.
Juices
Apple juice
fl oz.
Calcium added
Orange juice
fl oz.
Calcium added
fl oz.
Calcium added
Grape juice
1
NSLP AFTERSCHOOL SNACK FORM (EXPANDED)
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
F.
G.
Recipe?
B.
USDA Food?
A.
Vegetables (if offered with a dip, list the dip as a separate item in the condiments section)
Carrots, raw
cup
Celery, raw
cup
Whole grain-rich
Whole grain-rich Reduced-fat
Specify toppings:________________
Whole grain-rich
Combination Items and Entrées
Peanut butter & jelly sandwich
Pizza
Sandwich
1 sandwich
oz.
1 sandwich
Meat and Meat Alternates
Cheese
oz.
Reduced-fat
Specify type:___________________
Trail mix
oz.
Specify
ingredients:____________________
oz.
Regular Low-fat Fat-free
Light
Specify flavor(s):________________
Yogurt
2
NSLP AFTERSCHOOL SNACK FORM (EXPANDED)
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
F.
G.
Recipe?
B.
USDA Food?
A.
Breads and Grains
oz.
Whole grain-rich
Specify type: ___________________
Bagel
oz.
Whole grain-rich
Specify type:___________________
Cereal
Cookie
oz.
Corn/tortilla chips
oz.
Whole grain-rich
Specify type:___________________
Whole grain-rich
Specify type:___________________
Whole grain-rich
Specify type:___________________
Crackers
ea.
oz.
Whole grain-rich
Specify type:___________________
Granola bar
oz.
Whole grain-rich
Soft
Hard
Salted
Unsalted
Whole grain-rich
Whole grain-rich
Whole grain-rich
Pretzels
Desserts and Other Items
Fruit snacks/fruit leather
Fruit drink (less than 100% juice)
fl oz.
Specify flavor(s):________________
Pudding
Condiments
Reg Red. fat Low-fat
Fat-free
Reg Red. fat Low-fat
Fat-free
Ranch dip
Cream cheese
Ketchup
3
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CACFP AFTERSCHOOL SNACK AND SUPPER FORM (GROUP 3)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
SCHOOL NUTRITION AND MEAL COST STUDY-II
CACFP Afterschool Snack and Supper Form (Expanded)
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name: __________________________________________________________________
1. Please indicate the days that CACFP afterschool snacks and/or suppers were prepared
or served during the target week:
□
□
□
□
□
Monday
Tuesday
Wednesday
Thursday
Friday
This page has been left blank for double-sided copying.
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
CACFP Afterschool Snack and Supper Form (Expanded)
Tue
A.
Wed
Thu
Fri
B.
Number of Reimbursable Snacks and/or Suppers Served Onsite: _________
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
F.
G.
Check Box if
Prepared from
a Recipe
Mon
Check Box if
USDA Food
Day:
Milk
White
fl oz.
Fat-free/skim
1%
2%
Chocolate
Other flavor, Specify:
____________________
Other flavor, Specify:
____________________
fl oz.
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
fl oz.
fl oz.
Fruit
Apple, fresh
Applesauce, canned
Sweetened
cup
Unsweetened
Banana, fresh
Fruit cocktail, canned
Heavy syrup
Extra light syrup
Water
cup
Light syrup
Juice
Orange, fresh
Raisins
oz.
Juices
Apple juice
fl oz.
Calcium added
Orange juice
fl oz.
Calcium added
Grape juice
fl oz.
Calcium added
1
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
F.
G.
Recipe?
B.
USDA Food?
A.
Vegetables (if offered with a dip or salad dressing, list as a separate item in the condiments section)
Carrots, raw
cup
Celery, raw
cup
Salad, tossed
cup
French fries
cup
Oven-baked
Deep-fried
Combination Items and Entrées
Burrito
Cheeseburger
Entrée salad
Grilled cheese sandwich
Hamburger
Macaroni and cheese
Peanut butter & jelly sandwich
Pizza
Sandwich
Spaghetti with sauce
Bean
Chicken
oz.
Beef
Cheese
1
sandwich
List dressing as a separate item in
the condiments section
1
sandwich
1
sandwich
cup
Whole grain-rich
Whole grain-rich Reduced-fat
Specify toppings:
_____________________________
Whole grain-rich
Meat sauce Marinara sauce
Hard shell Soft tortilla
Bean
Beef
Chicken
Cheese
1 salad
1
sandwich
oz.
1
sandwich
cup
Taco
2
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
F.
G.
Recipe?
B.
USDA Food?
A.
Meat/Meat Alternates
Cheese
oz.
Reduced-fat
Specify type: __________________
Chicken nuggets (breaded)
ea.
Deep-fried
Oven-baked
Weight of each nugget: ________ oz
Chicken strips (not breaded)
oz.
Peanut butter
oz.
Reduced-fat
Trail mix
oz.
Specify ingredients:
_____________________________
oz.
Regular Low-fat Fat-free
Light
Specify flavor(s):
_____________________________
Yogurt
Breads and Grains
Bagel
oz.
Whole grain-rich
Specify type: __________________
Cereal
oz.
Whole grain-rich
Specify type: __________________
Cookie
oz.
Whole grain-rich
Specify type: __________________
oz.
Whole grain-rich
Specify type:___________________
Corn/tortilla chips
Crackers
ea.
Whole grain-rich
Specify type:___________________
Granola bar
oz.
Whole grain-rich
Specify type:___________________
3
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
C.
D.
E.
Number of Portions
Food Item
Pretzels
Portion
Size
(Incl.
Units)
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
oz.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
F.
G.
Recipe?
B.
USDA Food?
A.
Whole grain-rich
Soft
Hard
Salted
Unsalted
Whole grain-rich
Whole grain-rich
Whole grain-rich
Desserts
Fruit snacks/fruit leather
Fruit drink (not 100% juice)
fl oz.
Specify flavor(s): _______________
Pudding
Condiments
Reg Red. fat Low-fat
Fat-free
Reg Red. fat Low-fat
Fat-free
Ranch dip
Cream cheese
Ketchup
Mayonnaise
Reg Red. fat Low-fat
Fat-free
Reg Light Red. calorie
Fat-free
Reg Light Red. calorie
Fat-free
Mustard
Italian dressing
Ranch dressing
4
CACFP AFTERSCHOOL SNACK AND SUPPER FORM (EXPANDED)
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Incl.
Units)
Onsite
Sent
OffSite
Reimbursable
Prepared/
Available
Reimbursable
Served
F.
G.
Recipe?
B.
USDA Food?
A.
Other Menu Items
5
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NON-REIMBURSABLE FOODS FORM (GROUP 3)
This page has been left blank for double-sided copying.
NON-REIMBURSABLE FOODS FORM (EXPANDED)
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Non-Reimbursable Foods Form (Expanded)
NOTES:
For instructions on completing this form, please refer to Instructions for the Menu Survey.
Use this form to report foods that are sold solely on a non-reimbursable or a la carte basis and not available as part of a reimbursable meal or snack.
Include ONLY non-reimbursable foods that are supplied or stocked by foodservice.
For each food, record information on the number of portions either each day (in Column F) or as a total at the end of the week (in Column G).
School Store
E.
Off-Site
Other: _________________________
F.
G.
Daily Number of Portions
1
Weekly Total Number
of Portions
Wasted
Left Over for
Later Use
Sold Onsite
Sent Off-Site
Friday
Wasted
Left Over for
Later Use
Sold Onsite
Sent Off-Site
Thursday
Wasted
Left Over for
Later Use
Sold Onsite
Sent Off-Site
Wednesday
Wasted
Left Over for
Later Use
Food Description
Sold Onsite
Manufacturer/
Brand Name and
Product Code
Tuesday
Sent Off-Site
Monday
Wasted
Food Cart
Outside of Meal Periods
Left Over for
Later Use
Lunch
Sold Onsite
D.
Vending Machine
Wasted
Portion
Size
(Include
Units)
C.
Snack bar
Left Over for
Later Use
Food Name
B.
Check Box if Prepared
from a Recipe
A.
Serving line lunch
Sold Onsite
Where Offered: Serving line breakfast
Breakfast
Meal:
Sent Off-Site
School Name:_____________________________________________________
Sent Off-Site
•
•
•
•
Food Name
Portion
Size
(Include
Units)
Manufacturer/
Brand Name and
Product Code
Food Description
2
Wasted
F.
Left Over for
Later Use
Friday
Sold Onsite
Daily Number of Portions
Sent Off-Site
Wasted
Left Over for
Later Use
Thursday
Sold Onsite
Sent Off-Site
Wasted
Left Over for
Later Use
Wednesday
Sold Onsite
Sent Off-Site
Wasted
E.
Left Over for
Later Use
Tuesday
Sold Onsite
Sent Off-Site
Wasted
Left Over for
Later Use
Monday
Sold Onsite
Sent Off-Site
Wasted
D.
Left Over for
Later Use
C.
Sold Onsite
B.
Sent Off-Site
A.
Check Box if Prepared
from a Recipe
NON-REIMBURSABLE FOODS FORM (EXPANDED)
G.
Weekly Total Number
of Portions
A LA CARTE FOODS CHECKLIST (GROUP 3)
This page has been left blank for double-sided copying.
1
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
A La Carte Foods Checklist (Expanded)
SCHOOL NAME:
COMPLETE ON: [insert sticker with day of week]
DATE COMPLETED:
|
|
|/|
Month
|
Day
|/|
|
|
|
|
Year
Note: Please refer to the Instructions for the Menu Survey for instructions on completing this form.
1
1
A LA CARTE FOODS CHECKLIST (EXPANDED)
SCHOOL NUTRITION AND MEAL COST STUDY-II
A La Carte Foods Checklist (Expanded)
Food Item
A.
Breakfast
Milk
□
2 □
3 □
4 □
5 □
6 □
7 □
1.
Whole white milk
2.
Reduced fat (2%) white milk
3.
Low-fat (1% or 0.5%) white milk
4.
Fat-free/skim white milk
5.
Reduced fat (2%) flavored milk
6.
Low-fat (1% or 0.5%) flavored milk
7.
Fat-free/skim flavored milk
8.
Other milk beverages, including non-dairy milks (Specify)
1
□
8.2 □
8.3 □
8.4 □
8.5 □
a.
8.1
b.
c.
d.
e.
B.
□
2 □
3 □
4 □
5 □
6 □
7 □
1
□
8.2 □
8.3 □
8.4 □
8.5 □
8.1
100% Juice and Water
1.
C.
Lunch
□
2 □
Juice (100% fruit or vegetable juice)
1
2. Bottled water (plain, flavored, or sparkling)
Beverages Other than Milk, 100% Juice, or Water
1.
Diet carbonated soft drink (diet soda/pop)
2.
Regular carbonated soft drink (regular soda/pop)
□
2 □
3.
Juice drinks and other sweetened drinks (such as cranberry drink, Hi-C,
lemonade, fruit punch, iced tea)
3
1
4.
Sports drinks (such as Gatorade or PowerAde)
5.
Energy drinks (such as Red Bull or Monster Energy)
6.
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)
7.
Hot or cold coffee or tea
8.
Other beverages (Specify)
□
4 □
5 □
6 □
7 □
□
8.2 □
8.3 □
8.4 □
8.5 □
a.
8.1
b.
c.
d.
e.
1
□
2 □
1
□
2 □
1
□
4 □
5 □
6 □
7 □
3
□
8.2 □
8.3 □
8.4 □
8.5 □
8.1
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
D.
E.
Breakfast
Lunch
Fruit
1.
Dried fruit (such as raisins or apricots)
2.
Canned or frozen fruit
□
2 □
3 □
1
3. Fresh fruit
Vegetables
□
2 □
3 □
1
COOKED
1. Baked French fries (including tater tots and sweet potato fries)
2. Deep-fried French fries (including tater tots)
3. Potatoes or sweet potatoes (other than French fries/tater tots/sweet potato fries)
4. Corn
5. Carrots
6. Broccoli
7. Peas
8. Green beans
9. Mixed vegetables
10. Vegetable soup
11. Beans/legumes (such as baked beans, black beans, or pinto beans)
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
1
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
1
12. Other cooked vegetables (Specify)
□
12.2 □
12.3 □
12.4 □
12.5 □
a.
12.1
b.
c.
d.
e.
□
12.2 □
12.3 □
12.4 □
12.5 □
12.1
RAW (NOT COOKED)
13. Carrot sticks
□
14 □
15 □
16 □
17 □
18 □
13
14. Celery
15. Cucumbers
16. Salad bars
17. Tossed salads (side)
18. Prepared vegetable salads (such as potato salad, coleslaw, or three bean salad)
□
14 □
15 □
16 □
17 □
18 □
13
19. Other raw vegetables (Specify)
□
20.2 □
21.3 □
a.
19.1
b.
c.
2
□
20.2 □
21.3 □
19.1
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
Breakfast
□
23.5 □
d.
F.
22.4
e.
Breads and Grains
1.
Whole grain-rich breads, rolls, bagels, or tortillas
2.
Regular (not whole grain-rich) bread, rolls, bagels, or tortillas
3.
Other bread items (such as breadsticks, biscuits, croissants, or hot pretzels)
4.
Low-fat muffins
5.
Regular muffins (not lower in fat)
6.
Ready-to-eat breakfast cereal
7.
Pancakes, waffles, or French toast
8.
Rice, pasta, or cooked cereal
9.
Other bread/grains (Specify)
□
9.2 □
9.3 □
9.4 □
9.5 □
a.
b.
c.
d.
e.
G.
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
1
Lunch
□
23.5 □
22.4
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
1
□
9.2 □
9.3 □
9.4 □
9.5 □
9.1
9.1
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 □
13 □
14 □
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 □
13 □
14 □
Meats or Meat Alternates
1. Breaded chicken/turkey (nuggets, patties, strips, parts)
1
2. Not breaded chicken/turkey (nuggets, patties, strips, parts)
3. Breaded beef/pork (nuggets, patties, strips)
4. Not breaded beef/pork (nuggets, patties, strips)
5. Sausage or bacon
6. Breaded fish (nuggets, patties, strips/sticks)
7. Not breaded fish (nuggets, patties, strips/sticks, fillets)
8. Eggs
9. Cheese (including string cheese)
10. Fried or baked cheese or pizza sticks (for example, Bosco sticks)
11. Chili
12. Yogurt
13. Peanut butter or other nut or seed butter
14. Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)
3
1
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
Breakfast
Lunch
15. Other meats/meat alternates (Specify)
□
15.2 □
15.3 □
15.4 □
15.5 □
a.
15.1
b.
c.
d.
e.
H.
□
15.2 □
15.3 □
15.4 □
15.5 □
15.1
Entrees
SANDWICHES
1. Cheeseburger or hamburger
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
1
2. Hot dog or corn dog
3. Barbecue sandwich (including sloppy joes)
4. Peanut butter or other nut or seed butter sandwich (including with jelly)
5. Cheese sandwich
6. Veggie burger
7. Chicken, egg, or tuna salad sandwich
8. Sandwich with breaded meat, poultry or fish
9. Sandwich with cold cuts (salami, bologna, or pepperoni)
10. Sandwich with plain (not breaded) meat, poultry or fish
11. Breakfast sandwich or breakfast burrito
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
1
12. Other sandwiches (Specify)
□
12.2 □
12.3 □
12.4 □
12.5 □
a.
12.1
b.
c.
d.
e.
□
12.2 □
12.3 □
12.4 □
12.5 □
12.1
OTHER ENTREES
13. Pizza without meat
□
14 □
15 □
16 □
17 □
18 □
19 □
20 □
13
14. Pizza with meat
15. Calzone or Hot Pocket
16. Burritos
17. Other Mexican foods (such as tacos, nachos, or quesadillas)
18. Chinese food
19. Lasagna
20. Spaghetti
4
□
14 □
15 □
16 □
17 □
18 □
19 □
20 □
13
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
Breakfast
21. Macaroni and cheese
22. Entrée salad (such as chef’s, cobb, taco, or chicken Caesar)
23
□
22 □
23 □
21
Soup with meat or beans (such as chicken, clam chowder, or minestrone)
Lunch
□
22 □
23 □
21
24. Other entrees (Specify)
□
24.2 □
24.3 □
24.4 □
24.5 □
a.
24.1
b.
c.
d.
e.
I.
□
24.2 □
24.3 □
24.4 □
24.5 □
24.1
Baked Goods and Desserts
1. Low-fat/reduced-fat cakes, cupcakes, or brownies
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
1
2. Regular cakes, cupcakes, or brownies (not lower in fat)
3. Low-fat pies, turnovers, or toaster pastries
4. Regular pies, turnovers, or toaster pastries (not lower in fat)
5. Low-fat doughnuts or cinnamon rolls
6. Regular doughnuts or cinnamon rolls (not lower in fat)
7. Low-fat cookies
8. Regular cookies (not lower in fat)
9. Fruit crisp or cobbler
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
1
10. Other baked goods/desserts (Specify)
□
10.2 □
10.3 □
10.4 □
10.5 □
a.
10.1
b.
c.
d.
J.
e.
Frozen and Dairy Desserts
1.
Frozen fruit bars or popsicles
2.
Milkshakes, smoothies, or yogurt drinks
3.
Low-fat/reduced-fat ice cream, novelties, frozen yogurt, or sherbet
4.
Regular ice cream, novelties, frozen yogurt, or sherbet
5.
Pudding
□
2 □
3 □
4 □
5 □
1
5
□
10.2 □
10.3 □
10.4 □
10.5 □
10.1
□
2 □
3 □
4 □
5 □
1
A LA CARTE FOODS CHECKLIST (EXPANDED)
Food Item
6.
Breakfast
Other frozen/dairy dessert (Specify)
□
6.2 □
6.3 □
6.4 □
6.5 □
a.
6.1
b.
c.
d.
K.
Lunch
e.
Snacks
1. Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or
snack mixes)
2. Regular chips (not lower in fat; such as corn, potato, puffed cheese, tortilla, or
snack mixes)
3. Hard pretzels
4. Popcorn
5. Cracker sandwiches with cheese or peanut butter
6. Other types of crackers (including animal crackers)
7. Low-fat/reduced-fat granola bars, cereal bars, or energy bars
8. Regular granola bars, cereal bars, or energy bars (not lower in fat)
9. Crispy rice bars or treats
10. Candy or gum
11. Fruit snacks (such as Fruit Roll-Ups or fruit leather)
12. Meat snacks (such as jerky or pork rinds)
1
□
□
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 □
2
□
6.2 □
6.3 □
6.4 □
6.5 □
6.1
1
□
□
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 □
2
13. Other snacks (Specify)
□
13.2 □
13.3 □
13.4 □
13.5 □
a.
13.1
b.
b.
b.
L.
b.
Other A La Carte Items (Specify)
□
1.2 □
1.3 □
1.4 □
1.5 □
a.
1.1
b.
c.
d.
e.
6
□
13.2 □
13.3 □
13.4 □
13.5 □
13.1
□
1.2 □
1.3 □
1.4 □
1.5 □
1.1
NON-REIMBURSABLE FOODS INVENTORY (GROUP 3)
This page has been left blank for double-sided copying.
NON-REIMBURSABLE FOODS INVENTORY (EXPANDED)
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Non-Reimbursable Foods Inventory (Expanded)
NOTES:
For instructions on completing this form, please refer to the Instructions for the Menu Survey.
Use this form only if you are not able to report daily or weekly counts of units sold for each non-reimbursable food item.
Use this form to report foods that are sold solely on a non-reimbursable or a la carte basis and not available as part of a reimbursable meal or snack.
Be sure to inventory foods and beverages that are non-perishable, refrigerated, and frozen.
1
# Additional
Individual
Packages
Friday
Sent
Off-Site
Thursday
G.
Ending Onsite
Inventory
Received
Wednesday
Sent
Off-Site
Sent
Off-Site
Tuesday
Received
F.
Deliveries
(Number and/or Fraction of Full Bulk Container)
Monday
Manufacturer/Brand Name and Product
Code
Other: _________________
Sent
Off-Site
E.
Starting Onsite
Inventory
Off-Site
# Full Bulk
Cases
School Store
Received
D.
Food Cart
Sent
Off-Site
Vending Machine
Received
C.
Snack bar
# Additional
Individual
Packages
Food Name
B.
# Individual
Packages in Bulk
Case
A.
Serving line lunch
Individual Package
Size (Include Units)
Where Offered: Serving line breakfast
Meal: Breakfast Lunch Outside of Meal Periods
Received
School Name:____________________________________________
# Full Bulk
Cases
•
•
•
•
Food Name
B.
C.
# Individual
Packages in Bulk
Case
A.
Individual Package
Size (Include Units)
Manufacturer/Brand Name and Product
Code
2
Monday
Thursday
# Additional
Individual
Packages
F.
Deliveries
(Number and/or Fraction of Full Bulk Container)
# Full Bulk
Cases
Sent
Off-Site
Received
Sent
Off-Site
Sent
Off-Site
Wednesday
Received
Tuesday
Received
Sent
Off-Site
E.
Starting Onsite
Inventory
Received
Sent
Off-Site
Received
# Additional
Individual
Packages
D.
# Full Bulk
Cases
NON-REIMBURSABLE FOODS INVENTORY (EXPANDED)
G.
Ending Onsite
Inventory
Friday
MENU SURVEY ENHANCEMENTS ADMINISTERED THROUGH THE
ELECTRONIC MENU SURVEY (EMS) - EXPANDED (GROUP 3)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Questions Related to Offering Different Foods
and/or Portion Sizes to Students in
Different Grade Groups
Note: If the school includes students from more than one of the standard grade groups used in the
NSLP/SBP nutrition standards (computed based on responses to Screener Q7and Q7a), the EMS will
include additional questions on the Reimbursable Foods Form (for lunch and breakfast) that ask about
offering different foods and/or portion sizes to students in different grade groups.
[If school includes the following grade group combinations: K-5 and 6-8; K-5 and 9-12; 6-8 and 9-12; or K5, 6-8, and 9-12, ask the following questions:]
Reimbursable Foods Form for Lunch
1.
For reimbursable lunches, does your school offer the same menu to all students—meaning the same
foods and portion sizes—or does your school ever offer different foods and/or portion sizes to
students in different grade groups?
MARK ONE
1
2
□ School offers the same menu to all students (same foods and portion sizes).
□ School sometimes offers different foods and/or portion sizes to students in different grade
groups.
[If Q1 = 1, end; If Q1 = 2, ask Q2a]
2a. For reimbursable lunches, does your school offer different types of foods to students in different
grades (for example, younger students get tacos and older students get burritos)?
1
0
□
□
Yes
No
[If Q2a = Yes, ask Q2b; if Q2a = No, ask Q3a]
2b. For each of the following categories of foods, please indicate whether your school offers different
foods to different grade groups of students for reimbursable lunches.
MARK ONE PER ROW
YES
a. Milk
1
b. 100% fruit juices
1
c.
1
Fruits (excluding juice)
d. Vegetables
1
e. Entrée or meat/meat alternate items (such as sandwiches, pizza, entrée
salads, chicken tenders, cheese sticks)
1
f.
Bread and grain items offered separately (such as crackers, croutons,
rolls, tortilla chips)
1
g. Desserts, drinks, and snack items (such as cookies, fruit drinks, Jello)
1
h. Condiments and salad dressings
1
1
□
□
□
□
□
□
□
□
NO
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
3a. For reimbursable lunches, does your school offer different portion sizes of the same food to students
in different grade (for example, younger students get 3 oz burritos and older students get 5 oz
burritos)?
1
0
□
□
Yes
No
[If Q3a = No, skip to Q5]
3b. For each of the following categories of foods, please indicate whether your school offers different
portion sizes to different grade groups of students for reimbursable lunches.
MARK ONE PER ROW
YES
a. Milk
1
b. 100% fruit juices
c.
1
Fruits (excluding juice)
1
d. Vegetables
1
e. Entrée or meat/meat alternate items (such as sandwiches, pizza, entrée
salads, chicken tenders, cheese sticks)
f.
Bread and grain items offered separately (such as crackers, croutons,
rolls, tortilla chips)
g. Desserts, drinks, and snack items (such as cookies, fruit drinks, Jello)
h. Condiments and salad dressings
1
1
1
1
□
□
□
□
□
□
□
□
NO
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
[If Q2b or Q3b = Yes for a food category: When completing the Reimbursable Foods Form each day, the
SNM will indicate for each food under that food category: (1) which grade group(s) each food is offered to,
and (2) whether the food is offered in different portion sizes. For foods offered in different portion sizes,
the SNM will enter separate portion sizes for each relevant grade group.]
[If Q3a = Yes (offer different portion sizes)]
4.
For foods that are offered in different portion sizes, do you track how many servings of each portion
size were served to each grade group?
1
0
□
□
Yes
No
2
[If Q4 = Yes (track each portion size separately), SNM will be asked to report number of portions data
separately for each portion size for a given food. If Q4 = No (do not track each portion size separately),
SNM will be asked to report number of portions data across all available portion sizes.]
5.
On an average day, how many reimbursable lunches do you serve to students in each grade group?
[DISPLAY GRADE GROUPS FOR SCHOOL]
____ Students in grades K to 5
____ Students in grades 6 to 8
____ Students in grades 9 to 12
□ Don’t know
[Note: If Q4 = No (do not track each portion size separately), we will use data from Q5 to allocate the
combined number of portions data for a given food to the individual portion size associated with each
grade group. If Q5 = Don’t know, we attempt to get enrollment data by grade group to do this allocation.]
Reimbursable Foods Form for Breakfast
1.
For reimbursable breakfasts, does your school offer the same menu to all students—meaning the
same foods and portion sizes—or does your school ever offer different foods and/or portion sizes to
students in different grade groups?
MARK ONE
1
2
□ School offers the same menu to all students (same foods and portion sizes).
□ School sometimes offers different foods and/or portion sizes to students in different grade
groups.
[If Q1 = 1, end; If Q1 = 2, ask Q2a]
2a. For reimbursable breakfasts, does your school offer different types of foods to students in different
grades (for example, younger students get cereal and older students get muffins)?
1
0
□
□
Yes
No
3
[If Q2a = Yes, ask Q2b; if Q2a = No, ask Q3a]
2b. For each of the following categories of foods, please indicate whether your school offers different
foods to different grade groups of students for reimbursable breakfasts.
MARK ONE PER ROW
YES
a. Milk
1
b. 100% juice
c.
1
Fruits and vegetables (excluding juice)
1
d. Breakfast entrées and bread and grain items (such as breakfast
pizzas, sandwiches, cold or hot cereal, pancakes, French toast)
e. Meat/meat alternate items (such as eggs, sausage, yogurt)
f.
Condiments
1
1
1
□
□
□
□
□
□
NO
0
0
0
0
0
0
□
□
□
□
□
□
3a. For reimbursable breakfasts, does your school offer different portion sizes of the same food to
students in different grade (for example, younger students get 1 oz muffin and older students get 2
oz. muffin).
1
0
□
□
Yes
No
[If Q3a = No, skip to Q5]
3b. For each of the following categories of foods, please indicate whether your school offers different
portion sizes to different grade groups of students for reimbursable breakfasts.
MARK ONE PER ROW
YES
a. Milk
1
b. 100% juice
c.
1
Fruits and vegetables (excluding juice)
1
d. Breakfast entrées and bread and grain items (such as breakfast
pizzas, sandwiches, cold or hot cereal, pancakes, French toast)
e. Meat/meat alternate items (such as eggs, sausage, yogurt)
f.
Condiments
1
1
1
4
□
□
□
□
□
□
NO
0
0
0
0
0
0
□
□
□
□
□
□
[If Q2b or Q3b = Yes for a food category: When completing the Reimbursable foods Form each day, the
SNM will indicate for each food under that food category: (1) which grade group(s) each food is offered to,
and (2) whether the food is offered in different portion sizes. For foods offered in different portion sizes,
the SNM will enter separate portion sizes for each relevant grade group.]
[If Q3a = Yes (offer different portion sizes)]
4.
For foods that are offered in different portion sizes, do you track how many servings of each portion
size were served to each grade group?
1
0
□
□
Yes
No
[If Q4 = Yes (track each portion size separately), SNM will be asked to report number of portions data
separately for each portion size for a given food. If Q4 = No (do not track each portion size separately),
SNM will be asked to report number of portions data across all available portion sizes.]
5.
On an average day, how many reimbursable breakfasts do you serve to students in each grade
group?
[DISPLAY GRADE GROUPS FOR SCHOOL]
____ Students in grades K to 5
____ Students in grades 6 to 8
____ Students in grades 9 to 12
□ Don’t know
[Note: If Q4 = No (do not track each portion size separately), we will use data from Q5 to allocate the
combined number of portions data for a given food to the individual portion size associated with each
grade group. If Q5 = Don’t know, we attempt to get enrollment data by grade group to do this allocation.]
5
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
EMS Foods Paired/Offered Together Module
and Food Bar Questions
Note: The EMS will include additional questions that collect information needed for the compliance
assessment. This includes the “Foods paired/offered together” module in the Reimbursable Foods Forms
(for lunch and breakfast) and questions about salad bars.
1.
EMS FOODS PAIRED/OFFERED TOGETHER MODULE
The Reimbursable Foods Forms in the EMS will include a “foods paired/offered together” module.
After the school nutrition manager (SNM) reports all foods that were offered on a given day (and
associated food details), she will be taken to the “foods paired/offered together” module. The module
will be programmed to ask questions based on the specific foods reported on a given day.
If the menu day includes any separate grain items (for example, rice, rolls, or crackers) or any
meat/meat alternate items (for example, yogurt, string cheese, peanut butter), the SNM will be
asked if the item is served only with another item. If the SNM answers “yes”, they will be asked
to “pair” the items together (for example, the crackers were available only with the Chef’s salad).
After pairing items together, if 2 or more separate grain items or 2 or more separate meat/meat
alternate items are left “unpaired” the SNM will be asked how many of the “unpaired” items
students can select (separately for grains and meats/meat alternates).
2.
FOOD BAR QUESTIONS
If a side salad bar or entrée salad bar is reported, the EMS will ask the SNM a follow-up question
regarding the rules for visiting the bar.
[If Reimbursable Foods Form includes side salad bar, ask:]
Can students visit the side salad bar in addition to choosing other fruit or vegetable choices?
-
Yes, students can take fruits and vegetables from the side salad bar and also choose other fruits
and vegetables offered outside of the bar.
-
No, students can either visit the side salad bar OR take other fruit and vegetable choices offered
outside of the bar (but not both).
[If Reimbursable Foods Form includes entrée salad bar, ask]:
Can all students visit the entrée salad bar in addition to taking another entrée choice, or is the bar
considered a separate entrée choice?
-
All students can visit the entrée salad bar and also take another entrée choice.
-
Students can either visit the entrée salad bar OR take a different entrée choice offered outside of
the bar (but not both).
6
| File Type | application/pdf |
| File Modified | 2019-09-19 |
| File Created | 2019-06-19 |