Attachment G_SFSP Sample Site Review Form

Attachment G SFSP Sample Site Review Form

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

Sample Site Review Form
NOTE: To be completed during first four weeks of operation
Sponsor:

Site:

Site Contact Name:

Title:
Telephone:

Site Address:
Monitor’s arrival time:

Date of site visit:

Departure Time:

Site Supervisor:
 Open site

 Camp site

Average daily participation (if applicable):

Today’s attendance:
Types of meals reviewed:

Approved meal service time:
 Breakfast

 AM Snack

 Lunch

 PM Snack

 Dinner

Approved level of service:

Day of visit

Breakfast

AM Snack

Lunch

PM Snack

Dinner

# Meals delivered (if applicable)
# Meals/milk from previous day
Time meals delivered (if applicable)
Time meals served
# First meals served to children
# Second meals served to children
# Meals served to Program adults
# Meals served to non-Program adults
Discarded meals (dropped, spoiled,
incomplete meal, test meal*, etc.)
# Meals leftover
* Test meal cannot be claimed for reimbursement but should be recorded.

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Sample Site Review Form, Continued
Site Review Questions

Yes

No

1

Does the staffing pattern correspond to that listed on the approved site sheet?





2

Has the site supervisor attended training session?





3

Does the site have sufficient food service supervision?





4

Are meals counted/checked before signing delivery receipt?





5

Are accurate meal counts taken of meals served?





6

Are meals served as second meals excessive?





7

Are records of adult meals being kept?





8

Do meals meet approved menu?





9

Do meals meet meal pattern requirements?





10

Are meals checked for quality?





11

Is there proper sanitation/storage?





12

Is the site supervisor following procedures established to make meal order adjustments?





13

Are meals served within approved time frames?





14

Are all meals served and consumed on-site? (Note if State agency and sponsor allow
fruits/vegetables/grains to be taken off-site.)





15

Does site have a place to serve children meals in case of inclement weather?





16

Is each meal served as a unit?





17

Is the meal delivery schedule followed?





18

Are there provisions for storing or returning excess meals?





19

Is there documentation of children's income eligibility, if applicable?





20

Is there an “And Justice for All” poster, provided by the sponsor, on display in a
prominent place?





21

Are meals served to all attending children regardless of the child's race, color, national

origin, sex, age, or disability?





22

Do all children have equal access to services and facilities at the site regardless of the
child's race, color, national origin, sex, age, or disability?





23

Is informational material concerning the availability and nutritional benefits of the
Program available in appropriate languages and translations are accurate?





24

Are there reasonable modifications in policies and procedures to ensure individuals with
disabilities have equal access and effective communication when accessing the Program?





25

Are there reasonable steps in place to ensure meaningful access to services for limited
English proficient persons by providing information in the frequently encountered, non­
English languages of individuals eligible to be served or likely to be affected by the program?





29

Sample Site Review Form, Continued
Explain any “No” answers below:

Program Violations

Actual Count

1

Adult meals included in count of meals served to children.

2

Offsite consumption. (Do not include fruits/vegetables/grains
if allowed by State agency and sponsor).

3

More than one meal served at one time to children.

4

Meal pattern not met (specify):

5

Meals not served as a unit.

6

Meal serving times not met.

7

Other Program violations (specify):

Type of Meal

Check and explain if any of the following apply:
 No records

Explanation:

 Incomplete records

Explanation:

 Poor sanitation

Explanation:

 Other

Explanation:

Corrective action discussed with (Name and Title):
Corrective action taken:
Site supervisor’s comments:

Further action needed by (date):

I certify that the above information is correct:

Monitor’s Signature

Date

Sponsor Representative’s Signature

Date

Site Supervisor’s Signature

Date

30

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.