Food Service Management Company Manager and Regional Operations Manager - Businesses

School Nutrition and Meal Cost Study-II (SNMCS-II)

Appendix E2.2 Expanded Menu Survey Booklet (Full and Limited Outlying Areas)

Food Service Management Company Manager and Regional Operations Manager - Businesses

OMB: 0584-0648

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E2.2 EXPANDED MENU SURVEY BOOKLET: INSTRUCTIONS AND FORMS
(FULL AND LIMITED OUTLYING AREAS)

Menu Survey Screener – Expanded (Full and Limited Outlying Areas)
Daily Meal Counts Form (Full Outlying Areas)
Reimbursable Foods Form- Breakfast (Full and Limited Outlying Areas)
Reimbursable Foods Form – Lunch (Full and Limited Outlying Areas)
Recipe Form – Expanded (Full and Limited Outlying Areas)
Self-Serve/Made to Order Bar Form – Expanded (Full Outlying Areas)
Non-Reimbursable Foods Form (Full Outlying Areas)
Non-Reimbursable Food Inventory (Full Outlying Areas)

This page has been left blank for double-sided copying.

Menu Survey Forms Completed by:
Full-Approach Outlying Areas


Daily Meal Counts Form



Reimbursable Foods Forms for Lunch and Breakfast



Recipe Form



Self-Serve/Made-to-Order Bar Form



Non-Reimbursable Foods Form



Non-Reimbursable Foods Inventory

Limited-Approach Outlying Areas (to be completed at the SFA level)


Reimbursable Foods Forms for Lunch and Breakfast



Recipe Form

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

Instructions for the
Menu Survey (Expanded,
Outlying Areas)

Sponsored by:
U.S. Department of Agriculture
Food and Nutrition Service
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 8 hours
and 20 minutes per response for school nutrition managers in the full-approach outlying areas, and 3 hours and 30 minutes per
response for SFA directors in the limited-approach outlying areas, 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.

This page has been left blank for double-sided copying.

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 in the outlying areas, 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 [for full approach only] and sold a la carte or in other non-reimbursable venues.
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 used to estimate the cost of producing reimbursable
meals for the National School Lunch Program and School Breakfast Program. This study
is important because an accurate assessment of meal costs could eventually be used to
adjust per-meal reimbursement rates in outlying areas.
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.
Daily Meal Counts Form [full approach only]
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
detailed food descriptions. You will also indicate whether an item was a USDA Food or
prepared from a recipe.
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
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INSTRUCTIONS FOR EXPANDED MENU SURVEY

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 [full approach only]
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.
Non-Reimbursable Foods [full approach only]
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.
Non-Reimbursable Foods Form [full approach only]
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 [full approach only]
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!

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 [full approach only]
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 nonreimbursable 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.
Return all completed survey materials to Mathematica in the pre-addressed
envelope provided.

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 [for full
approach only] 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. [For full approach only] 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 [for full approach only] 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

cup

Chicken patty

2.5

oz.

Tossed salad

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.
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,
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INSTRUCTIONS FOR EXPANDED MENU SURVEY

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 [for full approach only]
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.

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.

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

120

160

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.

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)
Pizza, pepperoni
Super Donut
Pancake-on-a-stick

Manufacturer/Brand Name
and Product Code (Column D)
Schwan’s/Tony’s 78546
Super Bakery 6001
State Fair 70481

Column E: Food Description
This column is used to provide detailed descriptions of foods. 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.
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)

INSTRUCTIONS FOR EXPANDED MENU SURVEY

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.

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.

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.

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. 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.

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.

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. 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.

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.

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.

Food Name

B.
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.

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

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.
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
18

INSTRUCTIONS FOR EXPANDED MENU SURVEY

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.

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.



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.
20

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.
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
21

INSTRUCTIONS FOR EXPANDED MENU SURVEY

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.

MENU SURVEY SCREENER – EXPANDED (FULL AND LIMITED OUTLYING
AREAS)

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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.

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MENU SURVEY SCREENER QUESTIONS (EXPANDED)

Does your school participate in the School Breakfast Program (SBP)?
1
0

□
□

Yes
No

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.

□
□

Yes
No

School provides afterschool suppers through the CACFP.
1
0

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: ______________________________

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

□
□

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

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

□
□
□
□
□
□

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.]

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DAILY MEAL COUNTS FORM (FULL OUTLYING AREAS)

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OMB Control Number: 0584-xxxx
Expiration Date: xx/xx/xxxx

Daily Meal Counts Form (Expanded)
School Name:

Date:

Instructions:
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 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 $_________

$_________

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REIMBURSABLE FOODS FORM BREAKFAST (FULL AND LIMITED OUTLYING AREAS)

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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.

Day:

 Mon

 Tue

 Wed

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

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.

 Fat-free/skim

 1%

 2%

 Fat-free/skim

 1%

 2%

 Fat-free/skim

 1%

 2%

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

G.
Check Box if
Prepared from a
Recipe

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







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

G.
Check Box if
Prepared from a
Recipe

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

Kix

oz.



Lucky Charms

oz.



Marshmallow Mateys



Raisin Bran

oz.



Rice Chex



Rice Krispies

oz.



Trix

oz.



 Reg  Low-fat



REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
C.

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

G.
Check Box if
Prepared from a
Recipe

Check Box if
USDA Food



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




 Fruit

 Chocolate chip

 Other:____________
oz.



 Butter

 Low-fat
 Plain

Waffles



REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
C.

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

G.
Check Box if
Prepared from a
Recipe

Check Box if
USDA Food



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



 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

Weight of each stick:_________oz.



 Reduced-fat



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

G.
Check Box if
Prepared from a
Recipe

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

 Low sodium



 Sugar-free



REIMBURSABLE FOODS FORM: BREAKFAST (EXPANDED)
C.

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

G.
Check Box if
Prepared from a
Recipe

Check Box if
USDA Food



OTHER MENU ITEMS

This page has been left blank for double-sided copying.

REIMBURSABLE FOODS FORM:
LUNCH (FULL AND LIMITED OUTLYING AREAS)

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.

Day:

 Mon

 Tue

 Wed

 Thu

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)

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

G.
Check Box if
Prepared from a
Recipe

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



REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)

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

G.
Check Box if
Prepared from a
Recipe

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



REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)

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)

Food Description
 Oven-baked

 Deep-fried

G.
Check Box if
Prepared from a
Recipe






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








REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)

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

G.
Check Box if
Prepared from a
Recipe

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

REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)

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

G.
Check Box if
Prepared from a
Recipe

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

REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)

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

G.
Check Box if
Prepared from a
Recipe

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)

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



 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:_______________
 Butter
 Margarine



Breadstick

oz.

Specify type:_______________



Cornbread

oz.



Corn/tortilla chips

oz.


Specify type:_______________

Crackers

ea.

Croutons

oz.

Rice

cup

 White

Roll

oz.

Specify type:_______________




 Brown

 Wild



REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)

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

G.
Check Box if
Prepared from a
Recipe



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



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



REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)

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)

Food Description
 Reg  Light  Red. calorie
 Fat-free
 Reg  Light  Red. calorie
 Fat-free

G.
Check Box if
Prepared from a
Recipe



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



REIMBURSABLE FOODS FORM: LUNCH (EXPANDED)

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

G.
Check Box if
Prepared from a
Recipe



OTHER MENU ITEMS

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RECIPE FORM – EXPANDED (FULL AND LIMITED OUTLYING AREAS)

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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

 Tue

Lunch
3

3

Wed

Outside of Meal Periods
4

Thu

5

Fri

Size of One Serving (include units):
Number of Servings Prepared:

Ingredient Name

Amount in
Recipe
(Include
Units)

Manufacturer/
Brand Name and Product
Code
(If Applicable)

Ingredient Description

F.
Check Box if
Prepared
from a ecipe

1

Check Box if
USDA Food

Meal:



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SELF-SERVE/MADE-TO-ORDER BAR FORM - EXPANDED (FULL
OUTLYING AREAS)

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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

Portion Size,
If
Pre-portioned
(Include units)

Manufacturer/
Brand Name and
Product Code (if
applicable)

Food Description

5

Thu

6

Fri

F.
Check Box if
Prepared from
a Recipe

Meal:

Name of Bar:

Check Box if
USDA Food

School
Name:



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NON-REIMBURSABLE FOODS FORM (FULL OUTLYING AREAS)

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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

 Off-Site

 Other: _________________________

Daily Number of Portions









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

 Vending Machine

Wasted

Portion
Size
(Include
Units)

 Snack bar

Left Over for
Later Use

Food Name

Check Box if Prepared
from a Recipe

 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



Wasted

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

Left Over for
Later Use

Tuesday
Sold Onsite

Sent Off-Site

Wasted

Left Over for
Later Use

Monday
Sold Onsite

Sent Off-Site

Wasted

Left Over for
Later Use

Sold Onsite

Sent Off-Site

A.
Check Box if Prepared
from a Recipe

NON-REIMBURSABLE FOODS FORM (EXPANDED)

Weekly Total Number
of Portions

NON-REIMBURSABLE FOODS INVENTORY (FULL OUTLYING
AREAS)

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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.

# Additional
Individual
Packages

Friday

Sent
Off-Site

Thursday

G.
Ending Onsite
Inventory

Received

Wednesday

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

 Food Cart

Sent
Off-Site

 Vending Machine

Received

 Snack bar

# Additional
Individual
Packages

Food Name

# Individual
Packages in Bulk
Case

 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

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

Wednesday

Received

Tuesday

Received

Sent
Off-Site

E.
Starting Onsite
Inventory

Received

Sent
Off-Site

Received

# Additional
Individual
Packages

# Full Bulk
Cases

NON-REIMBURSABLE FOODS INVENTORY (EXPANDED)
G.
Ending Onsite
Inventory

Friday

File Type	application/pdf
Subject	Instructions
Author	Denise Mercury, Liz Condon
File Modified	2019-09-19
File Created	2019-06-19