HMI Subgrant Final Report Form Example form for A61 June 23-2022

OMB Control No.: 0584-0512

Expiration Date: xx/xx/xxxx

OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are 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 0584-0512. The estimated average time required to complete this information collection is 4 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. 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, ATTN: PRA (0584-xxxx*). Do not return the completed form to this address. Floor, Alexandria, VA 22314^th1320 Braddock Place, 5^th Floor, Alexandria, VA 22314 ATTN: PRA (0584-0512).  Do not return the completed form to this address.

Healthy Meals Incentives

Final Progress Report

This form should be completed no later than 90 days after the grant period of performance and returned to the (cooperator). Provide information on the entire grant period of performance.

Recipient Organization Information

Provide the requested information below about the recipient organization.

Name of School Food Authority: __________________________________________________

Address: _____________________________________________________________________

City: ________________________________________________________________________

State: ________________________________________________________________________

ZIP: _________________________________________________________________________

Primary Point of Contact

Provide the requested information below about the primary point of contact for the grant project.

First Name: ___________________________________________________________________

Last Name: ___________________________________________________________________

Title: ________________________________________________________________________

Email: _______________________________________________________________________

Phone: _______________________________________________________________________

Date Report Submitted

Provide the date the report was submitted below.

Date: ________________________________________________________________________

Grant Project Summary

Provide a summary of your overall grant project using the table below. In the first column, write a description of the activity completed. In the second column, describe the purpose of the activity. In the third column, describe the outcomes of the activity. If applicable, include number of school sites benefited by the activity, student enrollment and grade levels of school sites,

A61

school nutrition professionals trained and hours of training provided, and major equipment purchased.

Activity and Description	Activity Purpose	Outcomes
		[number input] School sites benefited by activity [number input] Students enrolled at school sites benefited by activity [text input] Grade levels of school sites benefited by activity [number input] Hours of training for school nutrition professionals [number input] Number of school nutrition professionals trained [text input] List of equipment purchased [text input] Changes to school meals as a result of activity

+Add additional activities [User will be able to add rows for additional activities as needed]

Grant Challenges

Provide a summary of challenges faced during the entire grant period of performance and how they were overcome: ____________________________________________________________

Success Stories

Describe how the sub-grant helped your SFA meet Healthy Meals Incentives award criteria: ___________________________________________________________________

Timeline and Budget

Were there any activities you did not complete?

[ ] Yes [ ] No

If yes, please describe: __________________________________________________________

Was there any leftover funding?

[ ] Yes [ ] No

If yes, please describe: ___________________________________________________________

Healthy Meals Incentive Award Program

Have you applied to receive a Healthy Meals Incentive Award?

[ ] Yes [ ] No

If yes, list the award(s) for which you have applied: ____________________________________

When did you apply for the award(s): _______________________________________________

Have you received a Healthy Meals Incentive Award?

[ ] Yes [ ] No

If yes, list the award(s) received: ___________________________________________________