State and Local Burden - SA, SFA/LEA

Attachment N.13. School Data and Meal Pattern Error Form (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.

S-1, INST
INSTRUCTIONS FOR
School Data and Meal Pattern Error Form (S-1)
1)

2a)

OMB #0584-0006
Expiration Date
xx/xx/20xx

Indicate the type of school by checking [ X ] as many categories as apply. If a Special Provision Option
school, list the claiming percentages or funding levels used for the reviewed school's monthly claim for
reimbursement. For CEP schools, list the derived claiming percentage (ISP x multiplier).
Check [ X ] all types of meal service which apply to this individual school for both breakfast and lunch
meal service.

b)

Check [ X ] the Child Nutrition Programs that are offered at this school, i.e. National School Lunch
Program (NSLP), School Breakfast Program (SBP), Fresh Fruit and Vegetable Program (FFVP), Special
Mikl Program (SMP), Seamless Summer Option (SSO), and/or Afterschool Snack Program (ASP). For
Programs beyond SBP and NSLP, please refer to the Program's corresponding review forms, where all
identified errors will be captured.

c)

Check [ X ] if meal service is provided by a food service management company or meals are vended
and enter the name(s) of the company(ies).

d)

Indicate whether the school offers Nonprogram foods. Check [X] all that apply.

e)

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

f)

Indicate whether the school was the selected using the Meal Compliance Risk Assessment Tool as the
Targeted Menu Review Site for the review. If YES, indicate whether the school was classified as high or
low-risk from the Dietary Specification Assessment Tool and which targeted menu review method was
selected.

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.

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School Year 2018-2019

S-1, INST
5)

Enter the Average Daily Attendance (ADA) factor for SBP and NSLP and check [ X ] the source of the
ADA factor, Local (L), State (S), or National (N). The local factor may be an attendance factor supplied
by the SFA or one developed by the reviewer using local data. The reviewer should use the factor
which provides the most accurate reflection of the actual attendance for the review period for this
school. The attendance factor must be in decimal form rounded to three places.

6)

Enter the review period (month and year) and the number of serving days in the review period for both
breakfast and lunch.

7)

Record the time(s) when the breakfast and lunch service begins and ends.

8)

Indicate each location where breakfasts and lunches are served. If OTHER, describe the location or
setting in the coments section.

9)

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

10)

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.

11)

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.

12 and
12a)

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.

13)

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 overclaim; those with a negative (-) sign
indicate an underclaim.

14)

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.

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School Year 2018-2019

S-1, INST
15)

For the Review 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.

16 and
16a)

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
foods and dietary specifications (16A) that will be subject to fiscal action.

17)

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 overclaim; those with a negative (-) sign
indicate an underclaim.

18)

Indicate whether any of the errors identified at the reviewed school resulted in the termination of the
Performance Based Reimbursement rate for the SFA. Indicate if the error was from the Day of Review,
Review Period, or Both.

19)

Record the meal counts by category for the review school for the entire month of the on-site review.
See Fiscal action module of the Administrative Review guidance for details on how to obtain this
information.

20)

Record the meal counts by category for the reviewed school from the review period

21)

Record all unallowable and/or unsupported Fresh Fruit and Vegetable Program costs and/or FFVP
underclaims

22)

Record all snacks counted and/or claimed for reimbursement for the review period and day ofr review
which are identified as non-reimbursable and/or incorrectly consolidated. Enter the Differences with a
positive (+) sign indicate an underclaim; those with a negative (-) sign indicate an overclaim. This
includes snack disallowances due to PS 1 and PS 2 violations.

Ensure that only reimbursable snacks (observe the 2 component per snack requirement) are being
counted and claimed for reimbursement and that only one snack per child is being claimed.  Suggest
recording information on the O-1 for SMP and enter the information on the S-1 #23.
23)

Enter the school's counts and reviewer's counts for the Special Milk Program for the Day of Review.
Enter the school's counts, the SFA's counts, and the reviewers' counts for the Special Milk Program for
the review period. Calculate and record the differences. Differences with a positive (+) sign indicate an
overclaim; those with a negative (-) sign indicate an underclaim. This includes milk disallowances due
to PS 1 and PS 2 violations.

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School Year 2018-2019

S-1, INST
Examine the daily counting and claiming documentation for the most recent claim for reimbursement
for the school. Validate the number of milks claimed for reimbursement through an independent count
of the daily milk counts. Determine whether milks were correctly counted and claimed.  If there were
differences between the school's milk counts and the validated milk counts, answer NO and describe
the problem in the Comments section.  Indicate if the causes are nonsystemic or systemic. Record
differences on Other Meal Claim Errors, S-2 (Review form instructions) Suggest recording information
on the O-1 for SMP and enter the information on the O-1 #24.

24)

If Reculculation was required, indicate whether it was a Full Recalculation or Partial Recalculation. If
Full Recalculation was required, complete 24.A, 24.B., 24.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.

25)

If Reculculation was required, indicate whether it was a Full Recalculation or Partial Recalculation. If
Full Recalculation was required, complete 25.A, 25.B., 25.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 S-1 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.

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School Year 2018-2019

S-1
S-1
[ ] 1st Review
[ ] Follow -Up

Administrative Review
School Data and Meal Pattern Error Form

SFA:
School:
Address:
Name/Title of Person(s) Interviewed:

Date of Review:

Reviewers:
1. Type of School (check all that apply)
[ ] Public
[ ] Private
[ ] Charter
[ ] Regular
[ ] Boarding
[ ] RCCI
[ ] Other: _________________________
[ ] Pricing
[ ] Non-Pricing
[ ] Closed Campus
[ ] Open Campus
[ ] Traditional Schedule (# Days/per week: ____ )
[ ] Year Round Schedule
[ ] Single Track
[ ] Multi-Track (# of Tracks: _________ )
[ ] Special Provision Option: [ ] 1 [ ] 2 [ ] 3
[ ] Base Year
[ ] Non-Base Year
SFA Calculated Claiming Percentage (%) or Funding Level ($):
Free % or $ __________
Reduced % or $ ____________
SA Calculated Claiming Percentage (%) or Funding Level ($):
Free % or $ __________
Reduced % or $ ____________
[ ] Community Eligibility Provision (District-wide [ ])
SFA Calculated ISP: _______________________

2a. Type of Meal Service (check all that apply)
[ ] On-Site Preparation
[ ] Base/Central Kitchen
[ ] Pre-Packaged Satellite
[ ] Bulk Satellite
2b. CN Programs (Check all that apply)
[ ] NSLP
[ ] SBP
[ ] SMP
[ ] SSO
[ ] Afterschool Snacks
[ ] FFVP
2c. [ ] Food Service Management Company
[ ] Vended
Name: _________________________________________
2d. Nonprogram Foods (check all that apply)
[ ] Adult Meals
[ ] A la Carte
[ ] Vending to other CN program sites
[ ] Other
[ ] Catering
2e. Offer vs. Serve
[ ] Yes ( # of items required:_____)
[ ] No
2f. Was this school the Targeted Menu Review site for the review?
[ ] Yes
[ ] No
If yes, was the school high or low-risk according to the Dietary Specifications
Analysis Tool?
[ ] High-Risk
[ ] Low-Risk
If yes, which targeted menu review method was selected?
[ ] Option 1
[ ] Option 2
[ ] Option 3
[ ] Option 4
NSLP
COMMENTS
[ ] Pre-K-5
[ ] K-5
[ ] 6-8
[ ] 9-12

SA Verified ISP: __________________________
SFA Calculated Free Claiming %: ____________
SA Calculated Free Claiming %: _____________
Applications
NA [ ]
[ ] Electronic
[ ] Paper
SBP
[ ] NA
[ ] Pre-K-5
[ ] K-5
3. Grades Participating
[ ] 6-8
[ ] 9-12
4. Total # Students with
Program Access
5. Average Daily
Attendance Factor: ____
Attendance Factor: _________
Attendance Factor
[ ] L [ ] S [ ] N
[ ] L [ ] S [ ] N
6. Review Period
mo/yr: _______ # Serving Days:____
mo/yr: _______ # Serving Days:____
7. Length of Meal Service
[ ] Cafeteria
[ ] Cafeteria
[ ] Breakfast in the Classroom
[ ] Classroom
8. Location of Meal Service [ ] Grab and Go
[ ] Other (describe in comments)
[ ] Other (describe in comments)
9. # of points where meal
counts are taken
Additional Notes

July, 2015

S-1

Performance Standards 1 and 2
Day of Review
SBP
[ ] NA
NSLP
10. # of ineligible and/or
second meals counted
11. # meals served missing
meal components
[ ] Milk Type: _____
12. Incomplete Meals (# by [ ] Milk Type: _____
[ ] Food Quantities:_____
[ ] Vegetable Sub-Group: _____
violation type)
[ ] Food Quantities: _____
[ ] Whole-Grain Rich Foods: ____
**Repeat ONLY**
[ ] Whole-Grain Rich Foods: _____
12A. Other
[ ] Dietary Specifications: ____
[ ] Dietary Specifications: ____
**Repeat Only**
School
Difference (+/SA Count
SA Count
Difference (+/-) School Count
Count
)
13. Meal Counting and
F: _____ F: _____
F: _____
F: _____
F: _____
F: _____
Claiming Consolidation
R: _____ R: _____
R: _____
R: _____
R: _____
R: _____
Counts and Errors
P: _____ P: _____
P: _____
P: _____
P: _____
P: _____
T: _____ T: _____
T: _____
T: _____
T: _____
T: _____
Review Period
SBP
[ ] NA
NSLP
14. # of ineligible and/or
second meals counted
15. # meals served missing
meal components
[ ] Milk Type: _____
[ ] Milk Type: _____
16. Incomplete Meals (# by [ ] Food Quantities:_____
[ ] Vegetable Sub-Group: _____
[ ] Food Quantities: _____
violation type)
[ ] Whole-Grain Rich Foods: ____
[ ] Whole-Grain Rich Foods: _____
16A. Other
[ ] Dietary Specifications: ____
[ ] Dietary Specifications: ____
**Repeat Only**
17. Meal Counting and Claiming Consolidation Counts and Errors
School
SFA Count
Count
F: _____ F: _____
R: _____ R: _____
P: _____ P: _____
T: _____ T: _____
18. Did this school have
errors resulting in the
termination of the
Performance-Based
Reimbursement?
19. Uncorrected Meal
Counts, by Category, for
the Month of On-site
Review
20. Uncorrected Meal
Counts, by Category, for
the Review Period

Difference
(+/-)
F: _____ F: _____
R: _____ R: _____
P: _____ P: _____
T: _____ T: _____
Yes_____ No _____
SA Count

[ ] Day of Review
[ ] Review Period
[ ] Both
F
R
P
Total
F
R
P
Total

SBP

SBP

School Count
F: _____
R: _____
P: _____
T: _____

SFA Count
F: _____
R: _____
P: _____
T: _____

SA Count
F: _____
R: _____
P: _____
T: _____

F
R
P
Total
F
R
P
Total

COMMENTS

COMMENTS

COMMENTS

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

NSLP

NSLP

Additional Notes

July, 2015

S-1

Other Federal Program Reviews
Day of Review
Review Period
21. Fresh Fruit and
$ _____________________
$ ____________________
Vegetable Program
[ ] Overclaim OR [ ] Underclaim
[ ] Overclaim OR [ ] Underclaim
22. All Afterschool Snack Program Disallowances
A. Day of Review
B. Review Period
Difference (+/-)

Difference (+/-)

F:_____
F:_____
R:_____
R:_____
P:_____
P:_____
T: _____
T: _____
23. Special Milk Program Counting and Claiming Consolidation Errors
A. Day of Review
B. Review Period
Difference
School Count SA Count
School Count
SFA Count
SA Count
(+/-)
F: _____
F: _____ F: _____
F: _____
F: _____
F: _____
P: _____
P: _____ P: _____
P: _____
P: _____
P: _____
T: _____
T: _____ T: _____
T: _____
T: _____
T: _____

24. SBP

[ ] Full Recalculation
A. Month __________

Recalculation of Meal Claims
25. NSLP
[ ] Partial Recalculation
[ ] Full Recalculation
B. Operating Days __________
A. Month
__________

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

COMMENTS

Difference (+/)
F: _____
P: _____
T: _____

[ ] Partial Recalculation
B. Operating Days __________

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

School Year 2018-2019

July, 2015