State and Local Governments

APPENDIX F05.13. On-Site SS/MTO Bar Form (Group 3)

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 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 0.17 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

On-Site Self-Serve / Made-to-Order Bar Form

School Name: ____________________________________ Date: ______________ Employee ID: _____________________

School MPRID: ______________________

Name of Bar: _________________________________

Meal: o Breakfast o Lunch

A.	B.	C.				D.	E.	F.	G.
Food Name	Portion Size (Include Units if Pre-Portioned)	Production Information				Manufacturer/ Brand Name and Product Code (If Applicable)	Food Description	USDA Food?	Recipe?
		Amount at Beginning	Amount Added	Amount Left Over for Later Use	Amount Wasted
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o

If more ingredients are present on the bar, please continue to next page.

A.	B.	C.				D.	E.	F.	G.
Food Name	Portion Size (Include Units if Pre-Portioned)	Production Information				Manufacturer/ Brand Name and Product Code (If Applicable)	Food Description	USDA Food?	Recipe?
		Amount at Beginning	Amount Added	Amount Left Over	Amount Wasted
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o
								o	o