State and Local Burden - SA, SFA/LEA

Attachment N.17. SFA Data Summary Form (SFA-3)

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.

OMB #0584-0006
Expiration Date xx/xx/20xx
SFA-3

SFA DATA SUMMARY FORM

SFA Data Summary of Special Assistance Provision Non-Base Year reviews must be recorded on the Special Assistance Provision NonBase Year Data Summary Form , SFA-1A
1)
2)
3)
4)

List the name of the School Food Authority (SFA)
Record the total number of schools and the number of schools selected for review, by type.
List the Review Period. (Month and Year)
A-C. Record from Question 126 of the On-Site Assessment Tool.
D. Record from SFA-1, SFA Count of Reviewed Students (Block 4A)
E. Record from SFA-1, SA Count of Reviewed Students (Block 4B)
F. Record from SFA-1, Applications-- Missing Information (Block 1A)
G. Record from SFA-1, Applications - MIscategorized (Block 1B)
H. Record from SFA-1, Benefit Issuance Errors (Block 2)

5) NSLP Day of Review
A. Record total of all applicable S-1 form(s) (Blocks 10+11 + 12 + 12a) for the reported SFA
B. Record total of all applicable S-1 form(s) (Block 13) for the reported SFA
C. Record total of all applicable S-1 forms(s) (Block 19) for the reported SFA
D. Record total of all applicable S-1 forms(s) (Block 18) for the reported SFA
6) NSLP Review Period
A. Record total of all applicable S-1 form(s) (Blocks 14+15 + 16 + 16a) for the reported SFA
B. Record total of all applicable S-1 form(s) (Block 17) for the reported SFA
C. Record total of all applicable S-1 form(s) (Block 20) for the reported SFA
7) SBP Day of Review
A. Record total of all applicable S-1 form(s) (Blocks 10+11 + 12 + 12a) for the reported SFA
B. Record total of all applicable S-1 form(s) (Block 13) for the reported SFA
C. Record total of all applicable S-1 form(s) (Block 19) for the reported SFA
8) SBP Review Period
A. Record total of all applicable S-1 form(s) (Blocks 14+15 + 16 + 16a) for the reported SFA
B. Record total of all applicable S-1 form(s) (Block 17) for the reported SFA
C. Record total of all applicable S-1 form(s) (Block 20) for the reported SFA
9) After School Snack Day of Review
Record total of all applicable S-1 form(s) (Block 22A) for the reported SFA
10) After School Snack Review Period
Record total of all applicable S-1 form(s) (Block 22B) for the reported SFA
11) Total Overclaim(-)/Underclaim(+) $
A. NSLP - Enter the answer for the following calculation:
Total NSLP Fiscal Action as reported in the FA Summary Tab of the Fiscal Action Workbook minus the sum of Afterschool Snack
Adjustment totals from all NSLP tabs in the Fiscal Action Workbook
B. After School Snack - Enter sum of Afterschool Snack Adjustment fields from all NSLP tabs in the Fiscal Action Workbook
C. SBP - Enter Total SBP Fiscal Action amount as reported in the FA Summary Tab of the Fiscal Action Workbook
D. Underclaim Amount Paid to SFA - Enter total underclaim amount ($) paid to SFA
E. Check Yes or No if disregard was used for NSLP, SBP, and/or SMP
12) SMP Adjustments - Enter Total SMP Errors amount as reported in the FA Summary Tab of the Fiscal Action Workbook
13) FFVP Adjustments - Enter Total FFVP Errors amount as reported in the FA Summary Tab of the Fiscal Action Workbook
14) Resource Management - Select trigered Resource Management Risk Indicators as reported on the Rescource Management Risk
Indicator Tool for the reported SFA

SFA-3
[ ] 1st Review
[ ] Follow-Up

Administrative Review
SFA Data Summary
# _______

1. SFA Name

2. Number of Schools
SBP
NSLP
Prov 2
Prov 3
CEP

Total

SBP
NSLP
Prov 2
Prov 3

F. Total Application Errors by Type
Child or Houeshold Name
Case Number

A. [ ] 100% of students eligible for free and reduced price benefits
Total Applications Reviewed _______________________

Income Amount or Source
Social Security #
Adult Signature

B. [ ] 95% confidence level - SFA has an electronic system
Universe: __________

Sample Size: __________

G. Total # Applications
Miscategorized (#)
F ->R
F -> P
R -> P
R-> F

C. [ ] 99% confidence Interval - SFA has a manual or combined system
Universe: __________
Sample Size: __________
D. SFA Count of Reviewed Students
E. SA Count of Reviewed Students
Free
Free
Reduced
Reduced Price
Price

SFA Count SA Count

F
R
P

C. Meal Counts, by category, for
the month of the on-site review
D. Error resulting in termination of
performance based reimbursement

Day of Review [ ]

F
R
P

SFA Count SA Count

C. Meal Counts, by category, for
the month of the on-site review

Review Period [ ]

F
R
P

SA Count

Difference (+/-)

SA Count

Difference (+/-)

F
R
P

Both [ ]

F
R
P

C. Meal counts, by category, for
the review period
After School Snack
10. Review Period

9. Day of Review
All Errors

Total

School Breakfast Program
8. Review Period
A. Total # of Disallowed Meals
Difference (+/-)
SFA Count
B. Consolidation
F
Errors
R
P

7. Day of Review
A. Total # of Disallowed Meals
B. Consolidation
Errors

Total

C. Meal counts, by category, for
the review period
Yes [ ]
No [ ]

H. Total #
Benefit Issuance Errors
F -> R
F -> P
R -> P
R-> F

National School Lunch Program
6. Review Period
A. Total # of Disallowed Meals
Difference (+/-)
SFA Count
B. Consolidation
F
Errors
R
P

5. Day of Review
A. Total # of Disallowed Meals
F
R
P

Year

CEP

4. Certification and Benefit Issuance Review Method

B. Consolidation
Errors

3. Review Period
Month

Reviewed

Difference (+/-)

Free
Reduced
Paid

11. Total Overclaim(-)/Underclaim(+) $

Free
Reduced
Paid

All Errors

A. NSLP

$

B. After School
Snack

$

C. SBP
D. Underclaim
amount paid to SFA
E. Disregard

14. Resource Management
[ ] Maintenance of the Nonprofit Food Service Account
[ ] Paid Lunch Equity

12. SMP

$

Total

$

Total

$

13. FFVP

$
NSLP [ ] Yes [ ] No
SBP [ ] Yes [ ] No
SMP [ ] Yes [ ] No

[ ] Revenue from Nonprogram Foods
[ ] Indirect Costs

Difference (+/-)