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

APPENDIX B8. (INSTRUMENT A1) APPLICATION DATA ABSTRACTION FORM

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

FOURTH ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-IV)

A1. APPLICATION DATA ABSTRACTION FORM

APEC IV APPLICATION DATA ABSTRACTION FORM

DATE OF ABSTRACTION MM/DD/YYYY

DATA COLLECTOR NAME

DATA COLLECTOR ID

1. STUDENT INFORMATION

STUDENT FIRST NAME (required)	STUDENT LAST NAME (required)	STUDENT DOB (MM/DD/YYYY)
STUDENT WESTAT STUDY ID (required)	STUDENT GRADE
SCHOOL WESTAT STUDY ID (required)	SCHOOL NAME

2. IF NOT COMPLETING APPLICATION ABSTRACTION FORM, MARK REASON(S) BELOW: (required if not completing form)

 DIRECT CERTIFICATION STUDENT (NO APPLICATION)

 Acceptable Documentation of direct certification confirmed

 Acceptable Documentation of direct certification NOT confirmed

 DIRECT CERTIFICATION STUDENT (W/ APPLICATION)

 Acceptable Documentation of direct certification confirmed

 Acceptable Documentation of direct certification NOT confirmed

 APPLICATION CANNOT BE FOUND

 APPLICATION HAS NOT BEEN SUBMITTED

 OTHER REASON → SPECIFY: _____________________________________

**********************************End Form*******************************

3. FORMAT IN WHICH APPLICATION WAS COMPLETED / SUBMITTED: (Check One, required)

 HARDCOPY OR PAPER APPLICATION, SUBMITTED IN PERSON, MAIL, FAX, OR EMAIL

 ONLINE (WEB-BASED)

 OTHER (SPECIFY: )

 UNKNOWN

4. SELECT ALL SOURCES USED TO COMPLETE APPLICATION DATA ABSTRACTION FORM: (Select All That Apply)

 HARDCOPY OR PAPER APPLICATION  VERBAL REPORT FROM STAFF

 ONLINE (WEB-BASED) APPLICATION  OTHER SOURCE (SPECIFY):_____________

 SCHOOL OR DISTRICT SUMMARY REPORT

E. HOUSEHOLD INFORMATION AND ELIGIBILITY STATUS: Complete the information below using the most recent school meal application completed for school year 2023-2024 for the student named in Section A.

	Complete this column (# 4 – 7) based on information from the school/district staff assessment
1. APPLICATION DATE | | |/| | |/| | || | | MONTH DAY YEAR  Not Available / Not Applicable	4. CERTIFICATION / ELIGIBILITY DETERMINATION DATE | | |/| | |/| | || | | MONTH DAY YEAR  Secondary Source Used (other than application)  Date Not Available / Not Applicable 5. SFA ASSESSMENT OF MEAL ELIGIBILITY STATUS  FREE  REDUCED-PRICE  DENIED / PAID  CATEGORICAL ELIGIBILITY - FREE  DIRECT CERTIFICATION - FREE  DIRECT CERTIFICATION - REDUCED-PRICE  SECONDARY SOURCE USED (OTHER THAN APPLICATION) 6. SFA’S ASSESSMENT OF HOUSEHOLD SIZE | | |  SECONDARY SOURCE USED (OTHER THAN APPLICATION)  Not Available / Not Applicable 7. SFA’S ASSESSMENT OF HOUSEHOLD INCOME $ | | | |,| | | |  WEEKLY  BI-WEEKLY  SEMI-MONTHLY  MONTHLY  ANNUAL  OTHER _________________  UNIT NOT REPORTED  SECONDARY SOURCE USED (OTHER THAN APPLICATION)  Not Available / Not Applicable
2. BASIS FOR ELIGIBILITY (select all that apply)  INCOME CATEGORICAL ELIGIBILITY  TANF  MEDICAID  SNAP  OTHER: __________  FDPIR  NOT SPECIFIED  CHECK IF CASE NUMBER RECORDED SPECIAL STATUS  FOSTER CHILD  MIGRANT  RUNAWAY  OBSERVED NEED  HOMELESS  INSTITUTIONALIZED / RESIDENTIAL CARE  OTHER (SPECIFY: ______________)
3. NUMBER OF STUDENTS COVERED BY APPLICATION | | |  UNKNOWN / UNSURE
COMMENTS ON HOUSEHOLD INFORMATION AND ELIGIBILITY STATUS:

F. HOUSEHOLD INCOME:

• List all household members (including children, students, and adults without income) and their income.

• The number recorded in this section should match the number of household members listed on the application, including the person who signed the application.

• If zero ($0) is reported as the income, record zero $0 – DO NOT LEAVE BLANK.

• INCOME LEFT BLANK: For each person, check Yes or No to indicate whether income was left blank.

• PERSON ADDED TO THE TABLE: For each person, check Yes or No to indicate whether you, the data collector, added the person to the income table.

• SECONDARY SOURCE: For each person, check Yes or No to indicate whether the income information was obtained from a secondary source (i.e. anything other than the application).

1.		2.		3.		4.		5.	6.	7.
LIST ALL HOUSEHOLD MEMBERS		EARNINGS FROM WORK		CHILD SUPPORT, OR ALIMONY (EXCLUDE SNAP, TANF)		PENSIONS, RETIREMENT, SOCIAL SECURITY OR ALL OTHER INCOME		PERSON ADDED TO TABLE	INCOME LEFT BLANK	SECONDARY SOURCE
FIRST NAME	LAST NAME	AMOUNT	PER W BW SM M Y OTH	AMOUNT	PER W BW SM M Y OTH	AMOUNT	PER W BW SM M Y OTH	Did you (data collector) add the HH member to the income table?	Was income for HH member left blank (not zero)?	Was income information obtained from secondary source
		$		$		$		 YES  NO	 YES  NO	 YES  NO
2.		$		$		$		 YES  NO	 YES  NO	 YES  NO
3.		$		$		$		 YES  NO	 YES  NO	 YES  NO

F8. Did the applicant select, check, circle, fill in, or enter the frequency of the income (i.e. weekly; bi-weekly; semi-monthly; monthly; yearly; or other) directly?

 YES

 NO

 NOT APPLICABLE

F10. Did SFA staff verbally provide/confirm the income frequency because it was not specifically indicated on the application?

 YES

 NO

 NOT APPLICABLE

F11. COMMENTS ON HOUSEHOLD INCOME:

G. FORM COMPLETENESS

	YES	NO
1. Was target student’s name listed on the application?	1	0
2. Was income recorded on the application for at least one household member?	1	0
3. Were the last four digits of the signer’s SSN recorded?	1	0
4. Was there an indication that signer does not have an SSN?	1	0
5. Was a case number recorded on the application?	1	0
6. Was the application signed?	1	0

H. COMMENTS SPECIFICALLY ON APPLICATION FORMAT:

I. OTHER GENERAL COMMENTS (Not related to application format):

J. 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.

Authority: This information is being collected under the authority of the Healthy, Hunger-Free Kids Act of 2010 (P. L. 111-296), Section 305.

Purpose: The Food and Nutrition Service (FNS) is collecting this information to assess improper payments made in the National School Lunch Program (NSLP) and School Breakfast Program (SBP).

Routine Use: The records in this system may be disclosed to private firms that have contracted with FNS to collect, aggregate, analyze, or otherwise refine records for the purpose of research and reporting to Congress and appropriate oversight agencies, and/or departmental and FNS officials.

Disclosure: Disclosing the information is voluntary, and there are no consequences to you as an individual for not providing the information. 

The System of Records Notice for this information collection is USDA/FNS-8, FNS Studies and Reports, which can be located at https://www.govinfo.gov/content/pkg/FR-1991-04-25/pdf/FR-1991-04-25.pdf (p. 19078).

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 1 hour (60 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.