E2_Pre-Visit Cost Form

E2. Pre-Visit Cost Form

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OMB Number: 0584-0669

Expiration Date: 10/31/2024

Study of Nutrition and Activity in Child Care Settings II (SNACS-II)

Pre-Visit Cost Form

Program/Respondent ID

Name: _________________________________

Title: __________________________________

Phone: (_____) _________________________

E-mail: _________________________________

Additional Respondent:

Name: _________________________________

Title: __________________________________

Phone: (_____) _________________________

E-mail: _________________________________

The Food and Nutrition Service (FNS) is collecting this information to understand the nutritional quality of CACFP meals and snacks, the cost to produce them, and dietary intakes and activity levels of CACFP participants. This is a voluntary collection and FNS will use the information to examine CACFP operations. The collection does request personally identifiable information under the Privacy Act of 1974. Responses will be kept private to the extent provided by law and FNS regulations. 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 0584-0669. The time required to complete this information collection is estimated to average 0.167 hours (10 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 22314. ATTN: PRA (0584-0669). Do not return the completed form to this address.

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About the Study. SNACS-II will look at the nutrition and wellness policies and activities in child care centers, family child care homes, and before-and-after-school programs across the country. This important study will help providers, sponsors, and USDA understand how CACFP operates so that it can better help children learn and grow. SNACS-II will provide an updated picture of CACFP and examine how key outcomes have changed since updated meal pattern requirements went into effect to encourage healthier eating. Mathematica and its partner, Westat, are conducting SNACS-II for USDA. Under the terms of Section 28 of the Richard B. Russell National School Lunch Act, institutions participating in CACFP are required to participate in this data collection.

Data Collection Activity. The Pre-Visit Cost Form is intended to gather information on meal counts and revenues related to food service operations and the CACFP. It is expected to take respondents approximately 10 minutes to complete the form.

Protecting Privacy. All information gathered from child care sponsors, child care centers, family child care homes, child care administrators and staff, and families participating in this study is for research purposes only and will be kept private to the full extent allowed by law. Responses will be grouped together. No staff, parents, or children will be identified by name. Being part of the study will not affect CACFP benefits for programs or families. Being part of the study will not affect any USDA benefits received by programs or families participating in this data collection.

Questions. If you have questions about the study please call us toll-free at [STUDY PHONE], email us at [STUDY EMAIL] or visit [URL]. We will be happy to answer your questions and to help you in any way we can.

Thank you for participating in the Study of Nutrition and Activity in Child Care Settings II.

SNACS-II PRE-VISIT COST FORM

This document should be completed by an administrator most familiar with food service/CACFP operations. Other agency personnel may need to assist in compiling information. Please return all pages by [DATE]. This document may be uploaded to [INSTRUCTIONS].

Please provide information on all CACFP activities (SPONSORS PROVIDE INFORMATION FOR CACFP ACTIVITIES FOR YOUR ORGANIZATION. INDEPENDENT CENTERS PROVIDE INFORMATION FOR THE SAMPLED CENTER). If you do not know certain information, please state this in the corresponding “Notes” section. Instructions for completing each section are included at the beginning of the section in italics.

This form includes the following sections:

1. Preliminary Food Service Revenue Statement

2. Annual CACFP Meal/Snack Counts

I. Preliminary Food Service Revenue Statement

Please upload a copy of your organization’s CACFP revenue statement for the Federal Fiscal Year Oct. 1, 2020 – September 30, 2021 (FFY 2021) with your completed Pre-Visit Cost Form. Child care centers should include CACFP revenues for the center; Sponsors should include all CACFP revenues for the organization.

• If your organization’s CACFP revenue statement is for a time period other than FFY 2021, please indicate the time period here: __________________________________

II. Annual CACFP Meal/Snack Counts

For FFY 2021, please provide counts of CACFP-eligible meals and snacks in the table below.

For centers or other sites that serve infants, toddlers, or preschoolers but no school-age children, put meal counts in Section A.

For centers or other sites that serve infants, toddlers, or preschoolers and also serve school-age children, put meal counts in Section B.

For centers or other sites that serve only serve school-age children, put meal counts in Section C.

If meal counts reported are for any time period other than FFY 2021, please indicate the time period here: __________________________________

• Notes: ___________________________________________________________________

Sponsors: provide data for all sponsored centers and programs

Independent centers: provide data for the sampled child care center

	A. Centers or sites serving infants, toddlers, or preschoolers, but no school-age children)			B. Centers or sites serving infants, toddlers, and/or preschoolers, and also school-age children)			C. Centers or sites serving only school-age children
	Total #:			Total #:			Total #:
Meal or Snack Type	# Paid	# Reduced price	# Free	# Paid	# Reducedprice	# Free	# Paid	# Reducedprice		# Free
Breakfast
Lunch
Supper
Snack

Thank you for completing this form. Please upload it and a copy of your organization’s CACFP revenue statement for FFY 2021 to [INSTRUCTIONS].