Attachment F_SFSP Sample First Week Visit Form

Attachment F SFSP Sample First Week Visit Form

OMB Control Number: 0584-0280
Expiration Date: 12/31/2022

Sample First Week Visit Form
Date of site visit:

Monitor’s arrival time:

Site name:

Departure Time:

Site address:

Discussion with site staff (list names):

Areas of Discussion

Notes and Observations

Has the site supervisor attended training session?
Are meals being counted and signed for?
Are all required records being completed?
Are meals served as second meals excessive?
Do meals meet meal pattern requirements?
Is there proper sanitation/storage?
Is the site supervisor following procedures established to make
meal order adjustments?
Are meals served at the time approved by the State agency?
Are all meals served and consumed on-site?
(Note if State agency and sponsor allow fruits/vegetables/
grains to be taken off site).
Is each meal served as a unit?
Are there any problems with delivery?
Is there documentation of children's income eligibility, if applicable?
Is there an “And Justice for All” poster, provided by the sponsor,
on display in a prominent place?

List any problems that were noted, and any corrective actions that were initiated to eliminate the problems:

Monitor’s Signature

Date

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This information is being collected from sponsoring organizations. Section 13 of the Richard B. Russell National
School Lunch Act (NSLA) 42 U.S.C. § 1758, as amended, authorizes the Summer Food Service Program for
Children (SFSP). 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 required by 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 0584-0280. The time required to
complete this information collection is estimated to average 2 hours and 30 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. 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, 1320 Braddock Place, Fifth Floor, Alexandria,
VA 22314, ATTN: PRA (0584-0280*). Do not return the completed form to this address.