State and Local Governments

Apppendix F06. Reimbursable Meal sale data request form

(Groups 2a and 2b)

This page has been left blank for double-sided copying.

This information is being collected to assist the Food and Nutrition Service in understanding school food purchasing practices, the nutritional quality of school meals and snacks, the cost to produce school meals, and student participation and dietary intakes. This is a mandatory collection and FNS will use the information to monitor program operations. This collection does request any personally identifiable information under the Privacy Act of 1974. 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-[xxxx]. The time required to complete this information collection is estimated to average 0.17 hours 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 Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

OMB Number:0584-xxxx

Expiration Date: xx/xx/20xx

Request for Data on Reimbursable Meal Sales

School Name:

School Mathematica ID # | | | | | | | | |

Interviewer Mathematica ID # | | | | | |

1. WRITE THE SCHOOL NAME AND MATHEMATICA ID ON PAGE 2 OF THIS FORM.

2. GIVE THE SCHOOL NUTRITION MANAGER PAGE 2. THEN REVIEW THE INSTRUCTIONS FOR PROVIDING THE REQUESTED INFORMATION.

3. INDICATE THE STATUS OF THE REQUEST BELOW.

□ Complete records were provided by the school .

□ Partial records were provided by the school. (Describe missing information, reason, and plans for follow up.)

□ No records were provided by the school. (Describe reason and plans for follow up.)

Request for Data on Reimbursable Meal Sales

Please indicate whether each student listed below received a reimbursable lunch and breakfast on the target date. Only provide Certification Status (column D) if it is blank. You can provide a report from your point-of-sale system with this information, or fill in the blank columns.

School Name:

School Mathematica ID # | | | | | | | | |

A	B	C	D	E	F
Student Name	Student ID	Target Date	Certification Status (Free, reduced price, paid)	Reimbursable lunch taken on target date? (Y=Yes, N=No)	Reimbursable breakfast taken on target date? (Y=Yes, N=No)
Example: Joe Smith	5555555	3/2/21	Reduced price	Y	Y