State and Local Governments

Appendix F08.03. school SOURCEs of Food Form (GROUPs 2a and 2b)

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School Name:

School ID:

Interviewer ID:

Date:

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 not 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 0.08 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

AMPM Source Screen Codes			Mark the times at which location is available			Mark the proportion of foods sold at the location that is reimbursable for . . .
						Breakfast					Lunch
	Name of Location (or Where Obtained)	Details on Location (or Where Obtained) (Check if present or describe)	Breakfast	Lunch	Other Times	All	Most	About Half	Small Amount	None	All	Most	About Half	Small Amount	None
2	Cafeteria line(s) - Reimbursable items only	□	□	□	□
3	Cafeteria line(s) - A La Carte items only	□	□	□	□
4	Cafeteria line(s) – Reimbursable and A La Carte items	□	□	□	□	□	□	□	□	□	□	□	□	□	□
5	Vending machine(s)	□ In cafeteria (indoor or outdoor seating/eating area)	□	□	□	□	□	□	□	□	□	□	□	□	□
6	Vending machine(s)	□ Outside but near (within 20 feet) cafeteria	□	□	□	□	□	□	□	□	□	□	□	□	□
7	Vending machine(s)	□ In other location on school grounds	□	□	□	□	□	□	□	□	□	□	□	□	□
8	Food cart(s)	□	□	□	□	□	□	□	□	□	□	□	□	□	□
9	Kiosk(s)	□	□	□	□	□	□	□	□	□	□	□	□	□	□
10	School store(s)	□	□	□	□	□	□	□	□	□	□	□	□	□	□
11	Snack bar(s)	□	□	□	□	□	□	□	□	□	□	□	□	□	□
12	Food truck(s)	□	□	□	□	□	□	□	□	□	□	□	□	□	□
13	FFVP snack	□
14	Afterschool program	□
15	Classroom	□
16	Class parties or teacher	□
17	Fundraiser(s)	□
18		□
19		□	□	□	□	□	□	□	□	□	□	□	□	□	□
20		□	□	□	□	□	□	□	□	□	□	□	□	□	□
21		□	□	□	□	□	□	□	□	□	□	□	□	□	□
22		□	□	□	□	□	□	□	□	□	□	□	□	□	□