State and Local Burden - SA, SFA/LEA

Attachment N.24. Supplemental Special Milk
Program Administrative Review Form

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.

SUPPLEMENTAL SPECIAL MILK PROGRAM ADMINISTRATIVE REVIEW FORM

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

School Food Authority:
School:
1

If the SFA is operating a pricing program, does the purchase price
of milk on the most recent claim for reimbursement match the
purchase price reflected on invoices? Are reimbursements being
used to reduce students’ payments?

YES

NO

N/A

Comments:

2

Do the daily milk count records support the most recent claim for
reimbursement?
If NO, explain and indicate if the problem was non-systemic or
systemic?

YES

NO

YES

NO

YES

NO

Record the milk counts claimed for reimbursement for the review
period and day of review (if on-site review is conducted) on S-1,
line 23.
Comments:
_____ Non-systemic

3

_____ Systemic

Do the milk service counting procedures yield accurate milk
counts?
If NO, explain and indicate if the problem was non-systemic or
systemic?
Record differences on S-1, line 23.

Comments:
_____ Non-systemic

4

_____ Systemic

Does the SFA properly retain all Special Milk Program records for
3 years after the final claim for reimbursement for the fiscal year
or until resolution of any audits?
If NO, explain.

Supplemental Special Milk Program Administrative Review Form
1

Last Updated School Year 2017-2018

SUPPLEMENTAL SPECIAL MILK PROGRAM ADMINISTRATIVE REVIEW FORM
Comments:

On-Site Observation Only

5

[ ]N/A

Does the school count milk at the point-of-service?

YES

NO

YES

NO

If NO, explain.
Record ineligible milks claimed for reimbursement on S-1, line 23.
Comments:
_____ Non-systemic

6

_____ Systemic

a. Are milk counts for the previous five days reasonable compared
to the milk count for the day of review?
b. If NO, obtain the school’s explanation and record in the
Comments section.
c. Does the explanation describe an acceptable meal count
system?
d. If NO, explain.
Record ineligible milks claimed for reimbursement on S-1, line 23.

Comments:

7

Did the SMP service follow HAACP principles and applicable sanitation
and health standards?
If NO, explain.

YES

NO

Comments:

Supplemental Special Milk Program Administrative Review Form
2

Last Updated School Year 2017-2018

SPECIAL MILK PROGRAM
ADMINISTRATIVE REVIEW INSTRUCTIONS
On-site observation of the SMP is only required if issues are discovered during the documentation
review or with meal counting and/or claiming of the NSLP or SBP.
1.

Determine that when milk is served to students eligible for free, the SFA is claiming the cost
being charged per half pint of milk. For paid milk in a pricing program, determine if milks are
being claimed at the current USDA rate of reimbursement. Determine that at schools with a
pricing program, reimbursements are being used to reduce the price charged to students.

2.

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 the milk counts claimed for reimbursement for the review
period and day of review (if on-site review is conducted) on S-1, line 23.

3.

Determine what procedure the school uses to count milks for reimbursement. Evaluate whether
the method yields an accurate milk count. If the procedure does not yield accurate milk counts,
answer NO and describe the problem in the Comments section. Indicate if the causes are
nonsystemic or systemic. Record differences on S-1, line 23.

4.

Determine if the school is retaining the appropriate records regarding program management for
3 years after the final Claim for Reimbursement for the fiscal year or until resolution of any
audits. If NO, explain in the Comments section.
On-Site Observation Only

5.

Observe and indicate whether an accurate count of milks is taken at the point of service or an
approved alternate. To answer YES, the system must be based on an actual count of milks
served and must consistently yield correct results. A NO answer is needed when an accurate
count of milks is not observed.
If NO, describe the problem and determine if the problem is nonsystemic or systemic. Record
ineligible milks claimed for reimbursement on S-1, line 23.

6.

7.

a. Obtain a copy of the milk counts for the previous five days and compare the counts to the day
of review count. If the counts from the previous five days are reasonable compared to the day
of review count, answer YES. If unreasonable shifts occurred in the counts from the previous five
days to the day of review count, answer NO.
b. If NO to a, obtain the school’s explanation and record in the Comments section.
c. Determine if the explanation describes an acceptable milk count system.
d. If NO, explain and record ineligible milks claimed for reimbursement on S-1, line 23.
Determine if the Special Milk Program meal service followed HACCP principles and applicable
sanitation and health standards. If NO, explain. See Food Safety module for HACCP principle
compliance requirements.

Supplemental Special Milk Program Administrative Review Form Instructions
3

School Year 2018-2019