State and Local Burden - SA, SFA/LEA/Schools

Attachment N.20. Seamless Summer Option School Data and Meal
Pattern Error Form (SSO S-1)

This information is being collected from State agencies, school food authorities, schools. This is a revision of a
currently approved information collection. The Richard B. Russell National School Lunch Act (NSLA) 42 U.S.C. §
1758, as amended, authorizes the National School Lunch Program (NSLP). This information is required to
administer and operate this program in accordance with the NSLA. Under the Privacy Act of 1974, any personally
identifying information obtained will be kept private to the extent of the 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 0584-0006. The time required to complete this information collection is estimated to
average 47.5 hours of reporting burden per response. The burden consists of the time it takes for the State agency
to conduct the off-site portion of the review which includes scheduling of the review and the completion of the
Off-site Assessment, Resource Management Risk Indicator, and Site Selection Tools. 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 Services, Office of Policy Support, 3101 Park
Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0006). Do not return the completed form to
this address.

SSO-S-1, INST
OMB #0584-0006
Expiration Date xx/xx/20xx
INSTRUCTIONS FOR
School Data and Meal Pattern Error Form (S-1)
1a)

Indicate the type of school by checking [ X ] as many categories as apply.

1b)

Check [ x ] for the type of site based on type of eligibility.

1c)

Check [ X ] all types of meal service which apply to this individual school for both breakfast, snack, and
lunch/supper meal service. If applicable, enter the name(s) of the company(ies).

1d)

Indicate whether the school offers Nonprogram foods.

1e)

Indicate whether the school implements Offer versus Serve. If YES, enter the number of required items
for a reimbursable meal.

1f)

Check [X] all types of approved meal service at this site and indicate approved meal service times.
NOTE: A maximum of two meals, such as lunch and breakfast, or lunch and a snack, or breakfast and a
snack, may be served per day per child at all sites, except migrant sites and camps.
At migrant sites and camps, a maximum of three meals may be served, such as breakfast, lunch and a
snack. Only migrant sites and camps may be reimbursed for lunch and supper served to the same
children on the same day.
For camps, both residential and non-residential, only the meals served to income eligible children
(based on free/reduced price applications) can be claimed for reimbursement. These meals are served
to eligible free and reduced priced children under the free reimbursement rate.

1g)

4. Check [X] all types of observed meal service at this site and indicate observed meal service times.

2)

Indicate whether applications are used at the site and if the process is paper or electronic.

3)

Select the grades from this school that participate in the SBP and NSLP. For example, if the children
in grades K - 12 have access to the NSLP, the selctions that represents grades K-12 should be
selected. (K-5, 6-8, and 9-12)

4)

Enter the total number of students who have access to the SBP and NSLP at this school. For example, if
kindergarten children attend the school but do not have access to the NSLP, this grade must be
excluded from grades that participate in the NSLP. This figure should encompass the time period for
the review period. If this number is not available, use the number which is most representative of the
review period. For schools on Year Round Multi-track Schedules, enter only the number of students
that has access during the review period. If two or more tracks were in attendance for only part of the
review period, the reviewer must obtain information for each of the time periods represented by the
various tracks of students. Reviewers should identify if there are visiting students that will be served in
the cafeteria or students not in school for reasons such as field trips or sickness on the day of review
and/or review period. Record any instances in the comments section.

5)

Enter the number of points where meal counts are taken for both breakfast and lunch.

6)

For the Day of Review, record the number of breakfasts and lunches served to ineligibles and/or
unallowable second breakfasts and/or lunches counted for reimbursement. This would include any
meals disallowed as a result of edit check activities.

7)

For the Day of Review, record the total number of breakfasts and lunches served and counted for
reimbursement from a meal service line that was missing a required component or breakfasts and/or
lunches being counted as reimbursable at the Point of Service which were missing a required
component. This includes meals where the required minimum amount of fruits and/or vegetables is
not selected under OVS. Only those meals served in error to eligible students are recorded in this
section.

8a and
8b)

For the Day of Review, check the appropriate category and record the total number of breakfasts
and/or lunches served and claimed for reimbursement that were incomplete due to violations in the
meal pattern requirements for milk types, vegetable sub-groups, food quantities, whole grain rich
foods and dietary specifications that will be subject to fiscal action. Only those meals served in error to
eligible students are recorded in this section.

9)

Enter the school's counts and the reviewer's counts for the Day of Review. Calculate and record the
difference. Differences with a positive (+) sign indicate an underclaim; those with a negative (-) sign
indicate an overclaim.

10)

For the Review Period, record the number of breakfasts and lunches served to ineligibles and/or
unallowable second breakfasts and/or lunches counted for reimbursement. This would include any
meals disallowed as a result of edit check activities.

11)

For theReview Period, record the total number of breakfasts and lunches served and counted for
reimbursement from a meal service line that was missing a required component or breakfasts and/or
lunches being counted as reimbursable at the Point of Service which were missing a required
component. This includes meals where the required minimum amount of fruits and/or vegetables is
not selected under OVS. Only those meals served in error to eligible students are recorded in this
section.

12a and
12b)

For the Review Period, check the appropriate category and record the total number of breakfasts
and/or lunches served and claimed for reimbursement that were incomplete due to violations in the
meal pattern requirements for milk types, vegetable sub-groups, food quantities, whole grain rich

13)

Enter the school's counts and the reviewer's counts for the Review Period. Calculate and record the
difference. Differences with a positive (+) sign indicate an underclaim; those with a negative (-) sign
indicate an overclaim.

14)

If Reculculation was required, indicate whether it was a Full Recalculation or Partial Recalculation. If
Full Recalculation was required, complete 14.A, 14.B., 14.C.
A: Record Month requiring recalculation. B: Record the number of operating days for the month
requiring recalculation. C: Obtain and record the 30 day count by category for the reviewed schools
from the SFA.

15)

If Reculculation was required, indicate whether it was a Full Recalculation or Partial Recalculation. If
Full Recalculation was required, complete 15.A, 15.B., 15.C.
A: Record Month requiring recalculation. B: Record the number of operating days for the month
requiring recalculation. C: Obtain and record the 30 day count by category for the reviewed schools
from the SFA.

NOTE:

The data recorded on the SSO-S1 will be transferred to the appropriate tab of the Fiscal Action
Workbook . See the Fiscal Action Module of the Administrative Review Manual. Additionally, hovers
have been included in the Fiscal Action Workbook for reference.

1

School Year 2018-2019

S-1

SSO-S-1

Administrative Review
School Data and Meal Pattern Error Form

[ ] 1st Review
[ ] Follow -Up
SFA:
Site:
Address:
Name/Title of Person(s) Interviewed:

Date of Review:

Reviewers:
1a. Type of Site (check all that apply)
[ ] Public
[ ] Private Non-Profit
[ ] School
[ ] Migrant
[ ] Camp
[ ] Other: _________
1b. Basis for Eligibility:
[ ] Area Eligible
[ ] Enrolled
1d. A la carte available
[ ] Yes
[ ] No
1f. Site Approved Meal Service Times

1c. Type of Meal Service (check all that apply)
[ ] On-Site Preparation
[ ] Base/Central Kitchen
[ ] Pre-Packaged Satellite
[ ] Bulk Satellite
[ ] Self-operation
[ ] FSMC
[ ] Vended
Name (if vended or FSMC): ________________________________
1e. Offer vs. Serve
[ ] Yes ( # of items required:_____)
[ ] No
1g. Observed Meal Service Times

[ ] Breakfast
[ ] AM Snack

__________ to ___________
__________ to ___________

[ ] Breakfast
[ ] AM Snack

__________ to ___________
__________ to ___________

[ ] Lunch
[ ] PM Snack
[ ] Supper

__________ to ___________
__________ to ___________
__________ to ___________

[ ] Lunch
[ ] PM Snack
[ ] Supper

__________ to ___________
__________ to ___________
__________ to ___________

2. Applications
[ ] Electronic

3. Grades Participating
4. Total # Students with
Program Access
5. # of points where meal
counts are taken

NA [ ]
[ ] Paper
SBP
[ ] NA
[ ] Pre-K-5
[ ] K-5
[ ] 6-8
[ ] 9-12

[ ] Pre-K-5
[ ] 6-8

NSLP/Supper
[ ] K-5
[ ] 9-12

COMMENTS

Additional Notes

Performance Standards 1 and 2

Day of Review

SBP

[ ] NA

NSLP/Supper

COMMENTS

6. # of ineligible and/or
second meals counted
7. # meals served missing
meal components
8a. Incomplete Meals (# by [ ] Milk Type: _____
violation type)
[ ] Food Quantities:_____
**Repeat ONLY**
[ ] Whole-Grain Rich Foods: ____

8b. Other
**Repeat Only**
9. Meal Counting and
Claiming Consolidation
Counts and Errors

[ ] Milk Type: _____
[ ] Vegetable Sub-Group: _____
[ ] Food Quantities: _____
[ ] Whole-Grain Rich Foods: _____

[ ] Dietary Specifications: ____

[ ] Dietary Specifications: ____

School
F: _____
R: _____
P: _____

SA Count
F: _____
R: _____
P: _____

Difference (+/F: _____
R: _____
P: _____

School Count SA Count
F: _____
F: _____
R: _____
R: _____
P: _____
P: _____

Difference (+/F: _____
R: _____
P: _____

T: _____

T: _____

T: _____

T: _____

T: _____

Review Period
SBP
[ ] NA
10. # of ineligible and/or
second meals counted
11. # meals served missing
meal components
12a. Incomplete Meals (#
[ ] Milk Type: _____
by violation type)
**Repeat ONLY**
[ ] Food Quantities:_____

NSLP/Supper

13. Meal Counting and
Claiming Consolidation
Counts and Errors

[ ] Vegetable Sub-Group: _____
[ ] Food Quantities: _____

[ ] Dietary Specifications: ____
School
SA Count Difference (+/F: _____ F: _____
F: _____
R: _____ R: _____
R: _____

P: _____
T: _____
14. SBP
[ ] Full Recalculation
A. Month __________

COMMENTS

[ ] Milk Type: _____

[ ] Whole-Grain Rich Foods: ____

12b. Other

T: _____

[ ] Whole-Grain Rich Foods: _____
[ ] Dietary Specifications: ____
School Count SA Count Difference (+/F: _____
F: _____
F: _____
R: _____
R: _____
R: _____

P: _____
T: _____

P: _____
P: _____
P: _____
P: _____
T: _____
T: _____
T: _____
T: _____
Recalculation of Meal Claims
15. NSLP/Supper
[ ] Partial Recalculation
[ ] Full Recalculation [ ] Partial Recalculation
B. Operating Days __________

C. Totals from 30 Day Recalculation Period
F: _________
R: _________
P: _________
T: _________

A. Month

__________

B. Operating Days __________

C. Totals from 30 Day Recalculation Period
F: _________
R: _________
P: _________
T: _________
Additional Notes

School Year 2018-2019

July, 2015