Appendix I - State Monitoring Plan Reporting Tool

OMB #: 0584-0654
Expiration date: 01/31/2022

Appendix I
State Monitoring Plan Reporting Tool

This information is being collected to assist the Food and Nutrition Service (FNS) to review the performance of State agencies’ and
eligible service providers’ Child Nutrition Program (CNP) operations under waiver authority, as required by Section 12(l) of the Richard
B. Russell National School Lunch Act (NSLA). This is a voluntary collection tool states may use to meet the reporting requirements
established in Section 12(l) of the NSLA, in FNS’ guidance, Child Nutrition Program Waiver Request Guidance and Protocol – Revised,
and statewide waiver approvals. FNS uses the information to ensure that waivers granted improve program operations while maintaining
program integrity, as well as review the performance of state agencies’ and eligible service providers’ CNP operations under waiver
authority, as required by the NSLA. This collection does request any personally identifiable information under the Privacy Act of 1974.
Responses will be kept private to the extent provided by law. 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 0584-0654. The time required to complete this information
collection is estimated to average 20 minutes (.334 hours) per response, including the time for reviewing instructions and searching
existing data sources. 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 22314 ATTN: PRA (0584-0654). Please do not return the completed form to this address.

State Monitoring Plan Reporting Tool

This form can be used to fulfill the quarterly reporting requirements for approved State
Monitoring Waiver plans.
Section 1

1. Please select your State Agency

Select your answer

2. Please select your FNS Regional office
Select your answer

3. Please input your email address
4. Please select the quarter you would like to report on below.
Select your answer
Section 2

Reporting Requirements

Please answer the questions below to fulfill your quarterly reporting requirement for your State plan.

5. Please provide a description of how the waiver impacted meal service
operations and eligible participants' access to nutritious meals and snacks.

6. Please provide a description of how the waiver has facilitated the State
agency's oversight abilities and responsibilities.

7. Please provide a summary of program integrity measures taken to identify
any misuse of Federal funds and identify fraudulent activities, and, if
anything was identified, any actions taken.

8. Please provide a description of how the waiver impacted the quantity of
paperwork necessary to administer the Program(s).

9. Please provide a summary of any technical assistance measures that were
provided.