Information Collection

State and Local Burden

IC 2879 under ICR 201909-0584-004 · OMB 0584-0006.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0006 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment T1. Off-site Assessment Tool.pdf	Other-Attachment T1: Off-site Assess
Attachment T2. On-site Assessment Tool.pdf	Other-Attachment T2: On-site Assessm
Attachment T3. Site Selection Worksheet.pdf	Other-Attachment T3: Site Selection
Attachment T4.Statistical Sample Generator.pdf	Other-Attachment T4: Statistical Sam
Attachment T5. Meal Compliance Risk Assessment Tool.pdf	Other-Attachment T5: Meal Compliance
Attachment T6. Dietary Specifications Assessment Tool.pdf	Other-Attachment T6: Dietary Specifi
Attachment T7. Nutrient Analysis and Validation Checklist.pdf	Other-Attachment T7: Nutrient Analys
Attachment T8. Nutrient Analysis Protocols.pdf	Other-Attachment T8: Nutrient Analys
Attachment T9. Resource Management Comprehensive Review Form.pdf	Other-Attachment T9: Resource Manage
Attachment T10. Resource Management Risk Indicator Tool.pdf	Other-Attachment T10: Resource Manag
Attachment T11. Fiscal Action Workbook.xlsx	Other-Attachment T11: Fiscal Action
Attachment T12. Non-reimbursable Meal Allocation Form.pdf	Other-Attachment T12: Non-reimbursab
Attachment T13. School Data and Meal Pattern Error Form (S-1).pdf	Other-Attachment T13: School Data an
Attachment T14. Other Meal Claim Errors (S-2).pdf	Other-Attachment T14: Other Meal Cla
Attachment T15. Eligibility and Certification and Benefit Issuance Error Worksheet.pdf	Other-Attachment T15: Eligibility Ce
Attachment T16. Other Eligibility Certification and Benefit Issuance Errors Worksheet (SFA-2).pdf	Other-Attachment T16: Other Eligibil
Attachment T17. SFA Data Summary Form (SFA-3).pdf	Other-Attachment T17: SFA Data Summa
Attachment T18. Special Provisions Non-Base Year and CEP Claiming Percentage Funding Level Summary Form SFA-1A.pdf	Other-Attachment T18: Special Provis
Attachment T19. Community Eligibility Provision ISP and Claiming Percentage Validation Worksheet (SFA-2A).pdf	Other-Attachment T19: Community Elig
Attachment T20. Seamless Summer Option School Data and Meal Pattern Error Form (SSO S-1).pdf	Other-Attachment T20: Seamless Summe
Attachment T21. Seamless Summer Option Eligibility Certification Form (SSO S-2).pdf	Other-Attachment T21: Seamless Summe
Attachment T22. Supplemental Seamless Summer Option Administrative Review Form.pdf	Other-Attachment T22: Supplemental S
Attachment T23. Supplemental Afterschool Snacks Administrative Review Form.pdf	Other-Attachment T23: Supplemental A
Attachment T24. Supplemental Special Milk Program Administrative Review Form.pdf	Other-Attachment T24: Supplemental S
Attachment T25. Infant and Pre-K Meal Pattern On-Site Validation Checklist.pdf	Other-Attachment T25: Infant and Pre
Attachment C. Form FNS-640 Administrative Review Data Report.pdf Attachment C: Form FNS-640 Administrative Review Data Report	IC Document
Attachment D. FPRS Home Screen.pdf Attachment D: OMB# 0584-0594 Food Programs Reporting System (FPRS) Home Screen with OMB Information and Public Burden Statement	IC Document
Attachment E. FNS-10 Report of School Operations.pdf Attachment E: Form FNS-10 Report of School Operations (OMB# 0584-0594)	IC Document
Attachment F. FNS-13 Annual Report of State Revenue Matching.pdf Attachment F: Form FNS-13 Annual Report of State Revenue Matching (OMB# 0584-0594)	IC Document
Attachment G. FNS-828 School Food Authority Paid Lunch Price Report.pdf Attachment G: Form FNS-828 School Food Authority Paid Lunch Price Report (OMB# 0584-0594)	IC Document
Attachment H. FNS-777 Financial Status Report.pdf Attachment H: Form FNS-777 Financial Status Report (OMB# 0584-0594)	IC Document
Attachment T. Administrative Review Guidance Manual 2018_2019.pdf Attachment T: Administrative Review Manual	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State and Local Burden

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 7 CFR 210.31(d)(2),(3) 7 CFR 210.11(b)(2) 7 CFR 210.5(d)(2)(ii) 7 CFR 210.9(b)(21),(c)(7) 7 CFR 210.18(m)(1) 7 CFR 210.31e(2),e(3) 7 CFR 210 7 CFR 210.11(b)(2) 7 CFR 210.15(a)(7) 7 CFR 210.5(d)(2)(ii) 7 CFR 210.18(i)(3) 7 CFR 210.18(c-h) 7 CFR 210.13(b) 7 CFR 210.18(h)(2)(iv) 7 CFR 210.9(b)(19) 7 CFR 210.31(a)&(c)(5) 7 CFR 210.20(b)(11),(b)(14) 7 CFR 210.10(m) 7 CFR 210.19(f) 7 CFR 210.20(a)(7) 7 CFR 210.15(a)(1) &210.8(b)&(c) 7 CFR 210.15(b)(1)

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Attachment T10: Resource Management Risk Indicator Tool	Attachment T10. Resource Management Risk Indicator Tool.pdf	No	Paper Only
Other-Attachment T18: Special Provisions Non-Base Year and CEP Claiming Percentage/Funding Level Summary Form (SFA-1A)	Attachment T18. Special Provisions Non-Base Year and CEP Claiming Percentage Funding Level Summary Form SFA-1A.pdf	No	Paper Only
Other-Attachment T23: Supplemental Afterschool Snacks Administrative Review Form	Attachment T23. Supplemental Afterschool Snacks Administrative Review Form.pdf	No	Paper Only
Other-Attachment T19: Community Eligibility Provison ISP and Claiming Percentage Validation Worksheet (SFA-2A)	Attachment T19. Community Eligibility Provision ISP and Claiming Percentage Validation Worksheet (SFA-2A).pdf	No	Paper Only
Other-Attachment T22: Supplemental Seamless Summer Option Administrative Review Form	Attachment T22. Supplemental Seamless Summer Option Administrative Review Form.pdf	No	Paper Only
Other-Attachment T24: Supplemental Special Milk Program Administrative Review Form	Attachment T24. Supplemental Special Milk Program Administrative Review Form.pdf	No	Paper Only
Other-Attachment T25: Infant and Pre-K Meal Pattern On-Site Validation Checklist	Attachment T25. Infant and Pre-K Meal Pattern On-Site Validation Checklist.pdf	No	Paper Only
Other-Attachment T2: On-site Assessment Tool	Attachment T2. On-site Assessment Tool.pdf	No	Paper Only
Other-Attachment T12: Non-reimbursable Meal Allocation Form	Attachment T12. Non-reimbursable Meal Allocation Form.pdf	No	Paper Only
Other-Attachment T13: School Data and Meal Pattern Error Form (S-1)	Attachment T13. School Data and Meal Pattern Error Form (S-1).pdf	No	Paper Only
Other-Attachment T5: Meal Compliance Risk Assessment Tool	Attachment T5. Meal Compliance Risk Assessment Tool.pdf	No	Paper Only
Other-Attachment T17: SFA Data Summary Form (SFA-3)	Attachment T17. SFA Data Summary Form (SFA-3).pdf	No	Paper Only
Other-Attachment T3: Site Selection Worksheet	Attachment T3. Site Selection Worksheet.pdf	No	Paper Only
Other-Attachment T4: Statistical Sample Generator	Attachment T4.Statistical Sample Generator.pdf	No	Paper Only
Other-Attachment T9: Resource Management Comprehensive Review Form	Attachment T9. Resource Management Comprehensive Review Form.pdf	No	Paper Only
Other-Attachment T16: Other Eligibility Certifcation and Benefit Issuance Errors Worksheet (SFA-2)	Attachment T16. Other Eligibility Certification and Benefit Issuance Errors Worksheet (SFA-2).pdf	No	Paper Only
Other-Attachment T21: Seamless Summer Option Eligibility Certification Form (SSO S-2)	Attachment T21. Seamless Summer Option Eligibility Certification Form (SSO S-2).pdf	No	Paper Only
Other-Attachment T1: Off-site Assessment Tool	Attachment T1. Off-site Assessment Tool.pdf	No	Paper Only
Other-Attachment T6: Dietary Specifications Assessment Tool	Attachment T6. Dietary Specifications Assessment Tool.pdf	No	Paper Only
Other-Attachment T15: Eligibility Certification and Benefit Issuance Error Worksheet (SFA-1)	Attachment T15. Eligibility and Certification and Benefit Issuance Error Worksheet.pdf	No	Paper Only
Other-Attachment T11: Fiscal Action Workbook	Attachment T11. Fiscal Action Workbook.xlsx	No	Paper Only
Other-Attachment T14: Other Meal Claim Errors (S-2)	Attachment T14. Other Meal Claim Errors (S-2).pdf	No	Paper Only
Other-Attachment T7: Nutrient Analysis and Validation Checklist	Attachment T7. Nutrient Analysis and Validation Checklist.pdf	No	Paper Only
Other-Attachment T8: Nutrient Analysis Protocols	Attachment T8. Nutrient Analysis Protocols.pdf	No	Paper Only
Other-Attachment T20: Seamless Summer Option School Data and Meal Pattern Error Form (SSO S-1)	Attachment T20. Seamless Summer Option School Data and Meal Pattern Error Form (SSO S-1).pdf	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 115,935

Number of Respondents for Small Entity: 115,499

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 96 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	47,631,996	12,918	-2,203,327	49,822,405
Annual IC Time Burden (Hours)	9,808,454	304,711	-526,257	10,030,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C: Form FNS-640 Administrative Review Data Report	Attachment C. Form FNS-640 Administrative Review Data Report.pdf	09/29/2019
Attachment D: OMB# 0584-0594 Food Programs Reporting System (FPRS) Home Screen with OMB Information and Public Burden Statement	Attachment D. FPRS Home Screen.pdf	09/29/2019
Attachment E: Form FNS-10 Report of School Operations (OMB# 0584-0594)	Attachment E. FNS-10 Report of School Operations.pdf	09/29/2019
Attachment F: Form FNS-13 Annual Report of State Revenue Matching (OMB# 0584-0594)	Attachment F. FNS-13 Annual Report of State Revenue Matching.pdf	09/29/2019
Attachment G: Form FNS-828 School Food Authority Paid Lunch Price Report (OMB# 0584-0594)	Attachment G. FNS-828 School Food Authority Paid Lunch Price Report.pdf	09/29/2019
Attachment H: Form FNS-777 Financial Status Report (OMB# 0584-0594)	Attachment H. FNS-777 Financial Status Report.pdf	09/29/2019
Attachment T: Administrative Review Manual	Attachment T. Administrative Review Guidance Manual 2018_2019.pdf	11/05/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.