State, Local, and Tribal Government - State Child Nutrition Agency, SFA, and Schools

APPENDIX B15. (INSTRUMENT D1). SCHOOL MEAL COUNT VERIFICATION FORM

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

Fourth Access, Participation, Eligibility and Certification Study Series (APEC IV)

D1. SCHOOL MEAL COUNT VERIFICATION FORM

SFA: | | | | | | | | |

School: | | | | | | | | |

School Type:

 Non-CEP, Non Provision 2 or 3

 CEP

 Provision 2 or 3 in non-base year

 Provision 2 or 3 in base year

Date: | | | / | | | / | | || | |

MM DD YYYY

Supplemental Reporting Form Required  NO  YES →Also complete Section G

(select one)

Does the school use an automated meal claiming system that automatically submits meal counts to SFA without any additional processing by school staff?  YES  NO

COMMENTS: _­___________________________

A. TARGET MONTH = October, 2023

A1. TARGET MONTH MEAL COUNTS

FOR PROVISION 2 OR 3 SCHOOLS OPERATING IN A NON-BASE YEAR OR A CEP SCHOOL, ENTER TOTAL COUNTS ONLY (LINE 4). FOR ALL OTHER (INCLUDING PROVISION 2 OR 3 SCHOOLS IN A BASE YEAR), ENTER ALL COUNTS.

1. BREAKFAST COUNT—MONTHLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—MONTHLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

IF SCHOOL ALSO KEEPS WEEKLY RECORDS, COMPLETE SECTION A2 – A6.

OTHERWISE, CONTINUE TO SECTION D: STUDENT INFORMATION.

A2. FIRST WEEK OF TARGET MONTH MEAL COUNT

From | | | / | | | / | | || || | to | | | / | | | / | | || ||| |

MM DD YYYY MM DD YYYY

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

A3. SECOND WEEK OF TARGET MONTH MEAL COUNT

From | | | / | | | / | | || || | to | | | / | | | / | | || ||| |

MM DD YYYY MM DD YYYY

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

A4. THIRD WEEK OF TARGET MONTH MEAL COUNT

From | | | / | | | / | | || || | to | | | / | | | / | | || ||| |

MM DD YYYY MM DD YYYY

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

A5. FOURTH WEEK OF TARGET MONTH MEAL COUNT

From | | | / | | | / | | || || | to | | | / | | | / | | || ||| |

MM DD YYYY MM DD YYYY

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

A6. FIFTH WEEK OF TARGET MONTH MEAL COUNT

From | | | / | | | / | | || || | to | | | / | | | / | | || ||| |

MM DD YYYY MM DD YYYY

1. BREAKFAST COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—WEEKLY TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

NOTE: THERE IS NO SECTION B NOR SECTION C.

D. STUDENT INFORMATION FOR SCHOOL

1. Total number of enrolled students: | | | |,| | | |

2. Average daily attendance: | | | |,| | | |

or

| | | |. | | | |% OR | |. | | | |

3. Number of serving days: | | | |,| | | |

IF SCHOOL IS PROVISION 2 OR 3 IN A NON-BASE YEAR, SKIP TO SECTION E.

IF SCHOOL IS CEP SCHOOL, SKIP TO SECTION F.

OTHERWISE, CONTINUE TO SECTION G OR H.

4. Number of students approved for free meals: | | | |,| | | |

5. Number of students approved for reduced-price meals: | | | |,| | | |

E. PROVISION 2 OR 3 CLAIMING PERCENTAGES FOR SCHOOL YEAR 2023-2024

COMPLETE ONLY FOR P2 OR P3 SCHOOL IN NON-BASE YEAR

CLAIMING PERCENTAGES FOR BREAKFAST:

1. Free Meals | | | |. | | | |% OR | |. | | | |

2. Reduced-Price Meals | | | |. | | | |% OR | |. | | | |

3. Paid Meals | | | |. | | | |% OR | |. | | | |

4. Base Year Period Used:

Yearly Percentages 1

Monthly Percentages 2

Specify Month and/or Year: | | | / | | || | |

CLAIMING PERCENTAGES FOR LUNCH:

5. Free Meals | | | |. | | | |% OR | |. | | | |

6. Reduced-Price Meals | | | |. | | | |% OR | |. | | | |

7. Paid Meals | | | |. | | | |% OR | |. | | | |

8. Base Year Period Used:

Yearly Percentages 1

Monthly Percentages 2

Specify Month and Year: | | | / | | || | |

F. CEP SCHOOL CLAIMING PERCENTAGES FOR SCHOOL YEAR 2023-2024

COMPLETE ONLY FOR CEP SCHOOL

CLAIMING PERCENTAGES:

1. Free Meals | | | |. | | | |% OR | |. | | | |

2. Paid Meals | | | |.| | | | % OR | |. | | | |

G. SUPPLEMENTAL REPORTING FORM

COMPLETE THIS SECTION IF THE SCHOOL RECORDS MEAL COUNTS ONTO AN INTERMEDIARY ‘SUPPLEMENTAL’ FORM AND THEN TRANSFERS THE MEAL COUNTS FROM THE SUPPLEMENTAL FORM ONTO ANOTHER FORM THAT IS SUBMITTED TO THE SFA.

RECORD THE INFORMATION FROM THE INTERMEDIARY “SUPPLEMENTAL REPORTING FORM” IN THIS SECTION CORRESPONDING TO THE SAME REFERENCE PERIOD (TARGET MONTH, WEEK, OR DAY)

G1. TOTAL MEALS REPORTED

FOR CEP SCHOOLS:

• ENTER REPORTED MEALS FOR FREE, PAID, AND TOTAL ONLY

• ENTER CLAIMING PERCENTAGES FOR FREE AND PAID ONLY

• DON’T INDICATE BASE PERIOD USED.

TOTAL BREAKFASTS FOR REFERENCE PERIOD		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | |. | | | |% OR | |. | | | |
2. Reduced-Price:	| | |,| | | |,| | | | | | |. | | | |% OR | |. | | | |
3. Paid (Full Price):	| | |,| | | |,| | | | | | | |. | | | |% OR | |. | | | |
4. Total Breakfasts:	| | |,| | | |,| | | |
		P2/3 BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
TOTAL LUNCHES REPORTED FOR REFERENCE PERIOD		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEP SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
5. Free:	| | |,| | | |,| | | | | | | |. | | | |% OR | |. | | | |
6. Reduced-Price:	| | |,| | | |,| | | | | | |. | | | |% OR | |. | | | |
7. Paid (Full Price):	| | |,| | | |,| | | | | | | |. | | | |% OR | |. | | | |
8. Total Lunches:	| | |,| | | |,| | | |
		P2/3 BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
IF REFERENCE PERIOD IS TARGET MONTH, AND SCHOOL ALSO KEEPS WEEKLY RECORDS, ALSO COMPLETE PARTS “G2-G6”. OTHERWISE, SKIP TO SECTION H

G2. FIRST WEEK OF TARGET MONTH
TOTAL BREAKFASTS
1. Free:	| | |,| | | |,| | | |
2. Reduced-Price:	| | |,| | | |,| | | |
3. Paid (Full Price):	| | |,| | | |,| | | |
4. Total Breakfasts:	| | |,| | | |,| | | |
TOTAL LUNCHES
5. Free:	| | |,| | | |,| | | |
6. Reduced-Price:	| | |,| | | |,| | | |
7. Paid (Full Price):	| | |,| | | |,| | | |
8. Total Lunches:	| | |,| | | |,| | | |

G3. SECOND WEEK OF TARGET MONTH
TOTAL BREAKFASTS
1. Free:	| | |,| | | |,| | | |
2. Reduced-Price:	| | |,| | | |,| | | |
3. Paid (Full Price):	| | |,| | | |,| | | |
4. Total Breakfasts:	| | |,| | | |,| | | |
TOTAL LUNCHES
5. Free:	| | |,| | | |,| | | |
6. Reduced-Price:	| | |,| | | |,| | | |
7. Paid (Full Price):	| | |,| | | |,| | | |
8. Total Lunches:	| | |,| | | |,| | | |

G4. THIRD WEEK OF TARGET MONTH
TOTAL BREAKFASTS
1. Free:	| | |,| | | |,| | | |
2. Reduced-Price:	| | |,| | | |,| | | |
3. Paid (Full Price):	| | |,| | | |,| | | |
4. Total Breakfasts:	| | |,| | | |,| | | |

TOTAL LUNCHES
5. Free:	| | |,| | | |,| | | |
6. Reduced-Price:	| | |,| | | |,| | | |
7. Paid (Full Price):	| | |,| | | |,| | | |
8. Total Lunches:	| | |,| | | |,| | | |

G5. FOURTH WEEK OF TARGET MONTH
TOTAL BREAKFASTS
1. Free:	| | |,| | | |,| | | |
2. Reduced-Price:	| | |,| | | |,| | | |
3. Paid (Full Price):	| | |,| | | |,| | | |
4. Total Breakfasts:	| | |,| | | |,| | | |
TOTAL LUNCHES
5. Free:	| | |,| | | |,| | | |
6. Reduced-Price:	| | |,| | | |,| | | |
7. Paid (Full Price):	| | |,| | | |,| | | |
8. Total Lunches:	| | |,| | | |,| | | |

G6. FIFTH WEEK OF TARGET MONTH
TOTAL BREAKFASTS
1. Free:	| | |,| | | |,| | | |
2. Reduced-Price:	| | |,| | | |,| | | |
3. Paid (Full Price):	| | |,| | | |,| | | |
4. Total Breakfasts:	| | |,| | | |,| | | |
TOTAL LUNCHES
5. Free:	| | |,| | | |,| | | |
6. Reduced-Price:	| | |,| | | |,| | | |
7. Paid (Full Price):	| | |,| | | |,| | | |
8. Total Lunches:	| | |,| | | |,| | | |

H. COMMENTS

Record any notes in the records, or reported to you by school staff that may be related to meal count records or data.

I. QC REVIEW (required)

 Check here to confirm that a QC review of the data entered was conducted, and all data entered is complete and accurate.

This information is being collected to provide the Food and Nutrition Service with key information on the annual error rates and improper payments for the school meal programs. This is a voluntary collection and FNS will use the information to examine school meal error rates and inform future APEC studies. This collection requests personally identifiable information under the Privacy Act of 1974. 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 0584-0530. The time required to complete this information collection is estimated to average 0.5 hours (30 minutes) per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22306 ATTN: PRA (0584-0530). Do not return the completed form to this address.

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