State and Local Burden - SA, SFA/LEA

Attachment N.15. Eligibility Certification and Benefit Issuance
Error Worksheet (SFA-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.

SFA-1, INST
OMB #0584-0006
Expiration Date xx/xx/20xx
Administrative Review
Eligibility Certification and Benefit Issuance Error Worksheet INSTRUCTIONS
GENERAL
COMMENTS

This form is used to record errors identified during the review of certification
and benefit issuance. Only list errors related to reviewed students in the
certification and benefit issuance sample. Other household members certified
or issued benefits in error whose eligibility or benefit issuance must be
corrected are listed on Other Eligibility Certification and Benefit Issuance Error
Worksheet , SFA-2
The worksheet must be completed regardless of the certification and benefit
issuance review method used. Provide a copy to the SFA no later than the exit
conference. If the reviewer did not identicy errors, check [ X ] N/A

SFA

Enter the name of the School Food Authority

[ ] 100%

Check if 100% of the free and reduced price eligible students were reviewed

STUDENT

The student's name or other identifier such as a student identification number
or application number is recorded in this space. When an identifier other than
the student's name is used, adequate information must be provided to the
SFA/school to identify the student(s) in error for corrective action purposes.

SFA ELIGIBILITY
DETERMINATION

Enter the studen't eligibility status from the point of service benefit issuance
document, free (F), or reduced-price ( R )

APPROVAL DATE

If there is no date on the eligibility certification document, attempt to
determine the date or approximate date of approval. This may be
accomplished by asking the individual(s) responsible for the maintenance of
the documents to provide an approval date, or by using the date the
application was signed by the parent or received by the SFA/school. If direct
certification, enter the date the certification was made. If it is not possible to
determine an approval date, the document is considered valid for the time
period being reviewed. In those situations where the approval date is not
known, enter a dash (-) in the space.

DIRECT
CERTIFICATION

Check [ 1 ] if the student was directly certified.

ELIGIBILITY BASED
ON
DOCUMENTATION

Check [1] if the student was determined eligible for free meal benefits based
on migrant, homeless, runaway, Headstart, foster child, or EvenStart status

TYPE OF ERROR

Check [1] the categories which identify(ies) each type of application or benefit
issuance error. More than one error may be identified for a student.

APPLICATIONS MISSING
INFORMATION

APPLICATIONS MISCATEGORIZED

BENEFIT ISSUANCE
ERRORS

Check [1] the category (missing information. Incomplete application errors
include missing child or household name (CH HH NM), lack of adult signature
(AD SIG), lack of social security number last four digits (SS#), missing income
amount or source (INC AMT SRC), missing case numbers (CS#), or other missing
information) that is necessary for an eligibility determination.

Check [1] as applicable
Miscategorized applications include: incorrectly calculating household size,
incorrectly determining the frequency of reciept of income, not converting
multiple income sources to annual income, not counting the child in the list of
household members or counting the child twice, incorrect arithmetic,
misclassifying reportable income, and other income computation errors.
Indicate the miscategorization, F/R, F/D, R/D or R/F.
Check [1] as applicable
Compare the eligibility certification documents (i.e. household applications,
direct certification, other categorically eligible student documentation) to the
benefit issuance document(s) used at the point of service to ensure students
are receiving the benefits for which they were approved.

An error exists when a free or reduced-price student is listed on the benefit
issuance document in an eligibility category other than the category for which
that student was approved, regardless of the correctness of the approval, or
the SFA does not have proper documentation for a student receiving free or
reduced-price benefits.
PS 1 VIOLATIONS

Indicate the correct level of benefits for each student as follows:
F -> R; F -> P; R -> P; R -> F. Total and transfer to the Fiscal Action Workbook,
Block 2.

DATE OF
CORRECTION

Technical assistance and corrective action will be required for all certification
and benefit issuance errors. Corrective action will be applied to all schools to
ensure that previously deficient practices and procedures are revised systemwide.

[ 1 ] IF VERIFIED

Check [1] if the student's application was verified. This application may count
towards the 10% verification sample.

DATA SUMMARY

Sum total the columns related to eligibility certification and benefit issuance
errors. The data summary row includes a formula to tabulate all entry in the
rows above in the tab. Any modifications made may affect the totals.
The total recorded on other forms to include the SFA-3 should include all SFA1 worksheet pages used during the eligibility cerification and benefit issuance
review.

COMMENTS

Enter appropriate comments related to eligibility certification, benefit
issuance, and corrective action
A. Enter SFA's count of reviewed students certified for free and reduced-price
meals by category. Transfer these counts to the Fiscal Action Workbook, Block
1.
B. Enter the SA's validated count of reviewed students certified for free or
reduced-price meals by category. Transfer these counts to the Fiscal Action
Workbook, Block 2.

COUNT OF
REVIEWED STUDENTS

C. Enter the SA's count of reviewed student errors. Divide by the total number
of reviewed students. Multiply result by 100 to determine the error
percentage. If the SFA's percentage in error is 10% or more; the SFA will be
required to conduct an Independent Review of Applications during the
subsequent school year.
D. Indicate by the drop down box whether the SFA has exceeded the 3% error
threshold.

1

ADMINISTRATIVE REVIEW
Eligibility Certification and Benefit Issuance Error Worksheet

SFA-1
SFA Name:

1. Eligibility Certification Errors
A.

Free / Paid

Reduced / Paid

Reduced / Free

Reduced received
Free

Free received
Reduced

Free

Reduced

0

Free / Reduced

DATA SUMMARY (Total for each Column)
0
If the application has missing information only, do not check any boxes under miscategorization

Adult Signature

[1] if Eligible by
Documentation

Social Security #
(last 4 digits)

[1] if
Directly
Certified

Income Amount or
Source

Approval
Date

Case Number

Eligibility
Status
(F/R)

0

0

0

0

0

0

0

0

0

0

0

0

0

Comments:
A. SFA count of reviewed students
Free: _________
Reduced Price: __________
Reviewer: ___________________________________

Page: ________

of

_______

B. Applications Miscategorized

Applications - Missing Information

Child or
Household Name

Student Name

2. Benefit Issuance Errors
Paid,
Received:

4. COUNT OF REVIEWED STUDENTS
B. SA count of reviewed students

Free: __________
Reduced Price: __________

3. PS 1
Violation

[ ] if
100%

Pick
Violation:
F -> R
F -> P
Date of
[ 1] if
R -> P
Correction verified
R -> F

0

C. Independent Review of Applications
Calulator

# of reviewed students: __________
Error Percentage: __________
School Year 2018-2019

Yes
No