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

APPENDIX B18 (Instrument C1). Meal Observation Booklet
OMB Number: 0584-0530
Expiration Date: XX/XX/XXXX

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.

Fourth Access, Participation, Eligibility and Certification Study
Series (APEC IV)
MEAL TRANSACTION OBSERVATION FORM

APPENDIX B18 (Instrument C1). Meal Observation Booklet

COMPLETE ONCE PER SCHOOL
SECTION A: SUMMARY
SFA Name and ID:

School Name and ID:

Date of Observation:

Data Collector Name & ID:

|

|
Month

|/|

Day

|

|/|

|
Year

|

|

|

Sampling Information and Results: List all registers/locations for each period. Period is
defined by non-overlapping start and end time.
PERIOD

1

Sampling Information
# of Registers or
Approximate #
PERIOD
Locations in
of students in
PERIOD
PERIOD
BREAKFAST
1

2

2

3

3

4

4

5

5

1

LUNCH

1

2

2

3

3

4

4

5

5

6

6

7

7

8

8

9

9

Sampling Notes:

Sampling Results
Location
# of
Start
Trays to
with
Observe

Interval

APPENDIX B18 (Instrument C1). Meal Observation Booklet

Sampling Information (continued):
location.

List all locations and provide a description for each

This will help you identify the location to observe per the sampling results.
BREAKFAST or LUNCH?
(circle one)

B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B

L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L

Location #

Description

APPENDIX B18 (Instrument C1). Meal Observation Booklet

COMPLETE ONE FOR EACH MEAL OBSERVATION
SECTION B: MEAL OBSERVATION DETAILS
Meal Type:  Breakfast

Meal Period: ___________

 Lunch

Time Observation Began:
|

Meal Service Delivery Type (select all
that apply)

Location of Observation:

 Cafeteria
 Multipurpose Room
 Gym
 Hallway
 Classroom # or Name:
Grade level(s): ______________

|

|

| AM

|

|/|

|

| AM

Meal Claiming Protocols
 Electronic
 Manual
 Other (specify):
____________________

_______________________________

 Other (specify):

|/|

 Cafeteria Staff
 Teacher
 Other (specify):

________________________

____________________

Offer Versus Serve (OVS)?  NO  YES
Total number of OVS Food Items Offered in meal service space: _________ (enter number)
Fruit and Vegetable
Quantity:
Fruit 1:
Fruit 2:
Fruit 3:
Vegetable 1:
Vegetable 2:
Vegetable 3:

¼

½

¾

1

½

1
(whole)

cup

cup

cup

cup









































































(half
portion)

____________
____________
_____________
_____________
_____________
_____________

Additional Notes:

PM

Time Observation Ended:

 Tray
 Bagged or boxed meal
 Pre-plated meal
 “Grab n Go” cart or Kiosk
 Vending machine
 Food/Salad bar
 Other (specify):

___________________

|

Additional Notes:

PM

APPENDIX B18 (Instrument C1). Meal Observation Booklet

Meal Level Exceptions (to be completed after meal observation):
(select all that apply)

 1. Could not observe all sampled meals (e.g., trays, boxes, bags, etc.)
Comments: ____________________________________________________________________________________

 2. Food item ran out, and was not replenished
Comments: ____________________________________________________________________________________

 3. Substitute Cashier
Comments: ____________________________________________________________________________________

 4. Atypical circumstance
Describe: ____________________________________________________________________________________

 5. IF THERE IS A FOOD BAR: Are food components/food items provided on the bars with the minimum serving size
for each food component/food item? Yes / No (circle one)

Additional notes:_________________________________________________________________________________

 6. IF THERE IS A FOOD BAR: Is there signage to show which foods and combinations of foods the students may
choose to select a reimbursable meal under OVS? Yes / No (circle one)
Additional notes:_________________________________________________________________________________

 7. NO CASHIER/REGISTER: describe how reimbursable meal status was determined:
______________________________________________________________________________________________

 8. OTHER EXCEPTION
Comments: ____________________________________________________________________________________
Additional Notes:

APPENDIX B18 (Instrument C1). Meal Observation Booklet
Tray #:  ______
Type of Participant:   

 Student    
 Non-Student    
 Adult
Tray Level Comments:

Tray Level Exceptions:

 E1. Did not observe tray
 E2. Did not observe all food components
 E3. Did not observe all food offered
 E4. Food item ran out with no replacement
item

Check
Number
if food
Food
of
item NOT
Servings Items
available
Taken
to student

NOTES:



1.



2.



3.



4.



5.



6.



7.



8.



9.



10.

Recorded as Reimbursable?     Yes      No

Tray #:  ______
Type of Participant:   

 Student    
 Non-Student    
 Adult
Tray Level Comments:

Tray Level Exceptions:

 E1. Did not observe tray
 E2. Did not observe all food components
 E3. Did not observe all food offered
 E4. Food item ran out with no replacement
item

NOTES:

Recorded as Reimbursable?     Yes      No

Check
Number
if food
Food
of
item NOT
Servings Items
available
Taken
to student



1.



2.



3.



4.



5.



6.



7.



8.



9.



10.

APPENDIX B18 (Instrument C1). Meal Observation Booklet
Breakfast Lunch
(circle one)

Food Items
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Breakfast Lunch
(circle one)

Food Items
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

APPENDIX B18 (Instrument C1). Meal Observation Booklet

Additional Notes:
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PLEASE WRITE CLEARLY. NOTES SHOULD BE LEGIBLE.