Appendix I - Competitive Foods Checklist

appendix I

competitive foods checklist

School Nutrition Dietary

Assessment Study IV

(OMB No.: 0584-0527)

Project Officer: Fred S. Lesnett

Office: Office of Research and Analysis

Food and Nutrition Service

Room 1014

3101 Park Center Drive

Alexandria, VA 22302

Telephone: 703-605-0811

FAX: 703-305-2576

Email: Fred.Lesnett@FNS.USDA.GOV

School Nutrition Dietary

Assessment Study

Vending Machines

(Simple)

Public reporting burden for this collection of information (forms for vending machines and other sources of foods/beverages) is estimated to average 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. 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 Service, Office of Research and Analysis, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0527). Do not return the completed form to this address.

OMB Clearance Number: 0584-0527

Expiration Date:

SCHOOL NUTRITION DIETARY ASSESSMENT STUDY

Vending Machines (Simple)

Please return completed form by fax to (609) 799-0005 (Attn: Annalee Kelly)

Your Name: Title:

Phone #: Date form completed:

School Name:

Does your school have any vending machines available to students during the day, including before or after school?

 Yes Continue  No Thank you. You are done. Please fax form to (609) 799-0005.

Instructions: Please provide the following information for every vending machine (anywhere on school grounds) that is available to students during the day, including before or after school.

A. BEVERAGE MACHINES	Beverage Machine 1	Beverage Machine 2	Beverage Machine 3	Beverage Machine 4	Beverage Machine 5
1. Machine Type Check here if machine contains beverages AND snacks	1 	1 	1 	1 	1 
2. Location Check only one location for each beverage machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of buttons OR front slots for each beverage machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Beverages Enter the number of front slots/buttons for each item
Diet carbonated soft drink (diet soda/pop)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular carbonated soft drink (regular soda/pop)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Juice (100% fruit or vegetable juice)	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Bottled water (plain, flavored, or sparkling)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Flavored milk (such as chocolate or strawberry)	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Whole or reduced fat (2%) white milk	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Low-fat (1%) white milk	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Fat-free/skim white milk	22 |______|	22 |______|	22 |______|	22 |______|	22 |______|
Other (Specify)	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|

B. SNACK MACHINES	Snack Machine 1	Snack Machine 2	Snack Machine 3	Snack Machine 4	Snack Machine 5
1. Machine Type Check here if this is a continuation of a machine that also includes beverages	1 	1 	1 	1 	1 
2. Location Check only one location for each snack machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of front slots OR buttons for each snack machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Snacks Enter the number of front slots/buttons for each item
Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Pretzels	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Popcorn	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Cracker sandwiches with cheese or peanut butter	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Other types of crackers (including animal crackers)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Low-fat/reduced-fat granola bars, cereal bars, or energy bars	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Regular granola bars, cereal bars, or energy bars	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Crispy rice bars or treats	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Candy	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Gum	22 |______|	22 |______|	22 |______|	22 |______|	22 |______|
Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Fruit snacks (such as Fruit Roll-Ups or fruit leather)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Meat snacks (such as jerky or pork rinds)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|
Other (Specify)	26 |______|	26 |______|	26 |______|	26 |______|	26 |______|
5. Baked Goods Enter the number of front slots/buttons for each item
Low-fat/reduced-fat cakes, cupcakes, or brownies	27 |______|	27 |______|	27 |______|	27 |______|	27 |______|
Regular cakes, cupcakes, or brownies	28 |______|	28 |______|	28 |______|	28 |______|	28 |______|
Low-fat pies, turnovers, or toaster pastries	29 |______|	29 |______|	29 |______|	29 |______|	29 |______|
Regular pies, turnovers, or toaster pastries	30 |______|	30 |______|	30 |______|	30 |______|	30 |______|
Doughnuts	31 |______|	31 |______|	31 |______|	31 |______|	31 |______|
Low-fat cookies	32 |______|	32 |______|	32 |______|	32 |______|	32 |______|
Regular cookies	33 |______|	33 |______|	33 |______|	33 |______|	33 |______|
Bread, rolls, bagels, or tortillas	34 |______|	34 |______|	34 |______|	34 |______|	34 |______|
Other (Specify)	35 |______|	35 |______|	35 |______|	35 |______|	35 |______|
6. Other Foods Enter the number of front slots/buttons for each item
Yogurt	36 |______|	36 |______|	36 |______|	36 |______|	36 |______|
Cheese	37 |______|	37 |______|	37 |______|	37 |______|	37 |______|
Frozen fruit bars, or popsicles	38 |______|	38 |______|	38 |______|	38 |______|	38 |______|
Milkshakes, smoothies, or yogurt drinks	39 |______|	39 |______|	39 |______|	39 |______|	39 |______|
Low-fat/reduced-fat ice cream, frozen yogurt, or sherbet	40 |______|	40 |______|	40 |______|	40 |______|	40 |______|
Regular ice cream, frozen yogurt, or sherbet	41 |______|	41 |______|	41 |______|	41 |______|	41 |______|
Dried fruit (such as raisins or apricots)	42 |______|	42 |______|	42 |______|	42 |______|	42 |______|
Canned fruit	43 |______|	43 |______|	43 |______|	43 |______|	43 |______|
Fresh fruit	44 |______|	44 |______|	44 |______|	44 |______|	44 |______|
Vegetables	45 |______|	45 |______|	45 |______|	45 |______|	45 |______|
Other (Specify)	46 |______|	46 |______|	46 |______|	46 |______|	46 |______|

School Nutrition Dietary

Assessment Study

Vending Machines

(Enhanced)

Your Name: Title:

Phone #: Date form completed:

School Name:

INSTRUCTIONS

• Please provide information for every vending machine (anywhere on school grounds) that is available to students during the day, including before and after school.

• When you are done reporting on your beverage machines, please turn to section B, page 5 to enter information about any snack machines.

• If your school has more than 25 beverage machines or more than 10 snack machines, please call Annalee Kelly at (609) 799-3535.

  Public reporting burden for this collection of information (forms for vending machines and other sources of foods/beverages) is estimated to average 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. 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 Service, Office of Research and Analysis, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0527). Do not return the completed form to this address.

A. BEVERAGE MACHINES	Beverage Machine 1	Beverage Machine 2	Beverage Machine 3	Beverage Machine 4	Beverage Machine 5
1. Machine Type Check here if machine contains beverages AND snacks	1 	1 	1 	1 	1 
2. Location Check only one location for each beverage machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of buttons OR front slots for each beverage machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Beverages Enter the number of front slots/buttons for each item
Diet carbonated soft drink (diet soda/pop)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular carbonated soft drink (regular soda/pop)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Juice (100% fruit or vegetable juice)	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Bottled water (plain, flavored, or sparkling)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Flavored milk (such as chocolate or strawberry)	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Whole or reduced fat (2%) white milk	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Low-fat (1%) white milk	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Fat-free/skim white milk	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Other (Specify)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|

	Beverage Machine 6	Beverage Machine 7	Beverage Machine 8	Beverage Machine 9	Beverage Machine 10
1. Machine Type Check here if machine contains beverages AND snacks	1 	1 	1 	1 	1 
2. Location Check only one location for each beverage machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of buttons OR front slots for each beverage machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Beverages Enter the number of front slots/buttons for each item
Diet carbonated soft drink (diet soda/pop)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular carbonated soft drink (regular soda/pop)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Juice (100% fruit or vegetable juice)	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Bottled water (plain, flavored, or sparkling)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Flavored milk (such as chocolate or strawberry)	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Whole or reduced fat (2%) white milk	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Low-fat (1%) white milk	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Fat-free/skim white milk	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Other (Specify)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|

A. BEVERAGE MACHINES (continued)	Beverage Machine 11	Beverage Machine 12	Beverage Machine 13	Beverage Machine 14	Beverage Machine 15
1. Machine Type Check here if machine contains beverages AND snacks	1 	1 	1 	1 	1 
2. Location Check only one location for each beverage machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of buttons OR front slots for each beverage machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Beverages Enter the number of front slots/buttons for each item
Diet carbonated soft drink (diet soda/pop)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular carbonated soft drink (regular soda/pop)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Juice (100% fruit or vegetable juice)	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Bottled water (plain, flavored, or sparkling)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Flavored milk (such as chocolate or strawberry)	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Whole or reduced fat (2%) white milk	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Low-fat (1%) white milk	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Fat-free/skim white milk	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Other (Specify)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|

	Beverage Machine 16	Beverage Machine 17	Beverage Machine 18	Beverage Machine 19	Beverage Machine 20
1. Machine Type Check here if machine contains beverages AND snacks	1 	1 	1 	1 	1 
2. Location Check only one location for each beverage machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of buttons OR front slots for each beverage machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Beverages Enter the number of front slots/buttons for each item
Diet carbonated soft drink (diet soda/pop)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular carbonated soft drink (regular soda/pop)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Juice (100% fruit or vegetable juice)	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Bottled water (plain, flavored, or sparkling)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Flavored milk (such as chocolate or strawberry)	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Whole or reduced fat (2%) white milk	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Low-fat (1%) white milk	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Fat-free/skim white milk	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Other (Specify)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|

A. BEVERAGE MACHINES (continued)	Beverage Machine 21	Beverage Machine 22	Beverage Machine 23	Beverage Machine 24	Beverage Machine 25
1. Machine Type Check here if machine contains beverages AND snacks	1 	1 	1 	1 	1 
2. Location Check only one location for each beverage machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of buttons OR front slots for each beverage machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Beverages Enter the number of front slots/buttons for each item
Diet carbonated soft drink (diet soda/pop)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular carbonated soft drink (regular soda/pop)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Juice (100% fruit or vegetable juice)	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Bottled water (plain, flavored, or sparkling)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Flavored milk (such as chocolate or strawberry)	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Whole or reduced fat (2%) white milk	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Low-fat (1%) white milk	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Fat-free/skim white milk	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Other (Specify)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|

B. SNACK MACHINES	Snack Machine 1	Snack Machine 2	Snack Machine 3	Snack Machine 4	Snack Machine 5
1. Machine Type Check here if this is a continuation of a machine that also includes beverages	1 	1 	1 	1 	1 
2. Location Check only one location for each snack machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of front slots OR buttons for each snack machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Snacks Enter the number of front slots/buttons for each item
Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Pretzels	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Popcorn	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Cracker sandwiches with cheese or peanut butter	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Other types of crackers (including animal crackers)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Low-fat/reduced-fat granola bars, cereal bars, or energy bars	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Regular granola bars, cereal bars, or energy bars	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Crispy rice bars or treats	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Candy	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Gum	22 |______|	22 |______|	22 |______|	22 |______|	22 |______|
Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Fruit snacks (such as Fruit Roll-Ups or fruit leather)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Meat snacks (such as jerky or pork rinds)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|
Other (Specify)	26 |______|	26 |______|	26 |______|	26 |______|	26 |______|
5. Baked Goods Enter the number of front slots/buttons for each item
Low-fat/reduced-fat cakes, cupcakes, or brownies	27 |______|	27 |______|	27 |______|	27 |______|	27 |______|
Regular cakes, cupcakes, or brownies	28 |______|	28 |______|	28 |______|	28 |______|	28 |______|
Low-fat pies, turnovers, or toaster pastries	29 |______|	29 |______|	29 |______|	29 |______|	29 |______|
Regular pies, turnovers, or toaster pastries	30 |______|	30 |______|	30 |______|	30 |______|	30 |______|
Doughnuts	31 |______|	31 |______|	31 |______|	31 |______|	31 |______|
Low-fat cookies	32 |______|	32 |______|	32 |______|	32 |______|	32 |______|
Regular cookies	33 |______|	33 |______|	33 |______|	33 |______|	33 |______|
Bread, rolls, bagels, or tortillas	34 |______|	34 |______|	34 |______|	34 |______|	34 |______|
Other (Specify)	35 |______|	35 |______|	35 |______|	35 |______|	35 |______|
6. Other Foods Enter the number of front slots/buttons for each item
Yogurt	36 |______|	36 |______|	36 |______|	36 |______|	36 |______|
Cheese	37 |______|	37 |______|	37 |______|	37 |______|	37 |______|
Frozen fruit bars or popsicles	38 |______|	38 |______|	38 |______|	38 |______|	38 |______|
Milkshakes, smoothies, or yogurt drinks	39 |______|	39 |______|	39 |______|	39 |______|	39 |______|
Low-fat/reduced-fat ice cream, frozen yogurt, or sherbet	40 |______|	40 |______|	40 |______|	40 |______|	40 |______|
Regular ice cream, frozen yogurt, or sherbet	41 |______|	41 |______|	41 |______|	41 |______|	41 |______|
Dried fruit (such as raisins or apricots)	42 |______|	42 |______|	42 |______|	42 |______|	42 |______|
Canned fruit	43 |______|	43 |______|	43 |______|	43 |______|	43 |______|
Fresh fruit	44 |______|	44 |______|	44 |______|	44 |______|	44 |______|
Vegetables	45 |______|	45 |______|	45 |______|	45 |______|	45 |______|
Other (Specify)	46 |______|	46 |______|	46 |______|	46 |______|	46 |______|
B. SNACK MACHINES (continued)	Snack Machine 6	Snack Machine 7	Snack Machine 8	Snack Machine 9	Snack Machine 10
1. Machine Type Check here if this is a continuation of a machine that also includes beverages	1 	1 	1 	1 	1 
2. Location Check only one location for each snack machine
In cafeteria (including indoor and outdoor seating/eating area)	2 	2 	2 	2 	2 
Outside but near (within 20 feet) cafeteria or seating/eating area	3 	3 	3 	3 	3 
Elsewhere in school building(s)	4 	4 	4 	4 	4 
Outside school building(s), but on school grounds (not in eating area)	5 	5 	5 	5 	5 
3. Capacity/Size Count and enter the number of front slots OR buttons for each snack machine
If slots are not visible: Enter # of selection buttons (not sold out)	6 |______|	6 |______|	6 |______|	6 |______|	6 |______|
Enter # of buttons that are sold out	7 |______|	7 |______|	7 |______|	7 |______|	7 |______|
Total # of buttons (available + sold out)	8 |______|	8 |______|	8 |______|	8 |______|	8 |______|
If slots are visible: Enter # of front slots that are filled	9 |______|	9 |______|	9 |______|	9 |______|	9 |______|
Enter # of front slots that are empty	10 |______|	10 |______|	10 |______|	10 |______|	10 |______|
Total # of front slots (filled + empty)	11 |______|	11 |______|	11 |______|	11 |______|	11 |______|
4. Snacks Enter the number of front slots/buttons for each item
Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	12 |______|	12 |______|	12 |______|	12 |______|	12 |______|
Regular chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	13 |______|	13 |______|	13 |______|	13 |______|	13 |______|
Pretzels	14 |______|	14 |______|	14 |______|	14 |______|	14 |______|
Popcorn	15 |______|	15 |______|	15 |______|	15 |______|	15 |______|
Cracker sandwiches with cheese or peanut butter	16 |______|	16 |______|	16 |______|	16 |______|	16 |______|
Other types of crackers (including animal crackers)	17 |______|	17 |______|	17 |______|	17 |______|	17 |______|
Low-fat/reduced-fat granola bars, cereal bars, or energy bars	18 |______|	18 |______|	18 |______|	18 |______|	18 |______|
Regular granola bars, cereal bars, or energy bars	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Crispy rice bars or treats	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Candy	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Gum	22 |______|	22 |______|	22 |______|	22 |______|	22 |______|
Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Fruit snacks (such as Fruit Roll-Ups or fruit leather)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Meat snacks (such as jerky or pork rinds)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|
Other (Specify)	26 |______|	26 |______|	26 |______|	26 |______|	26 |______|
5. Baked Goods Enter the number of front slots/buttons for each item
Low-fat/reduced-fat cakes, cupcakes, or brownies	27 |______|	27 |______|	27 |______|	27 |______|	27 |______|
Regular cakes, cupcakes, or brownies	28 |______|	28 |______|	28 |______|	28 |______|	28 |______|
Low-fat pies, turnovers, or toaster pastries	29 |______|	29 |______|	29 |______|	29 |______|	29 |______|
Regular pies, turnovers, or toaster pastries	30 |______|	30 |______|	30 |______|	30 |______|	30 |______|
Doughnuts	31 |______|	31 |______|	31 |______|	31 |______|	31 |______|
Low-fat cookies	32 |______|	32 |______|	32 |______|	32 |______|	32 |______|
Regular cookies	33 |______|	33 |______|	33 |______|	33 |______|	33 |______|
Bread, rolls, bagels, or tortillas	34 |______|	34 |______|	34 |______|	34 |______|	34 |______|
Other (Specify)	35 |______|	35 |______|	35 |______|	35 |______|	35 |______|
6. Other Foods Enter the number of front slots/buttons for each item
Yogurt	36 |______|	36 |______|	36 |______|	36 |______|	36 |______|
Cheese	37 |______|	37 |______|	37 |______|	37 |______|	37 |______|
Frozen fruit bars or popsicles	38 |______|	38 |______|	38 |______|	38 |______|	38 |______|
Milkshakes, smoothies, or yogurt drinks	39 |______|	39 |______|	39 |______|	39 |______|	39 |______|
Low-fat/reduced-fat ice cream, frozen yogurt, or sherbet	40 |______|	40 |______|	40 |______|	40 |______|	40 |______|
Regular ice cream, frozen yogurt, or sherbet	41 |______|	41 |______|	41 |______|	41 |______|	41 |______|
Dried fruit (such as raisins or apricots)	42 |______|	42 |______|	42 |______|	42 |______|	42 |______|
Canned fruit	43 |______|	43 |______|	43 |______|	43 |______|	43 |______|
Fresh fruit	44 |______|	44 |______|	44 |______|	44 |______|	44 |______|
Vegetables	45 |______|	45 |______|	45 |______|	45 |______|	45 |______|
Other (Specify)	46 |______|	46 |______|	46 |______|	46 |______|	46 |______|

OMB Clearance Number:

Expiration Date:

SCHOOL NUTRITION DIETARY ASSESSMENT STUDY

Other Sources of Foods/Beverages

Please return completed form by fax to (609) 799-0005 (Attn: Annalee Kelly)

Your Name: Title:

Phone #: Date form completed:

School Name:

Besides vending machines and food sold in the cafeteria, does your school have any other sources of food or beverages available to students during the day, including before or after school?

 Yes Continue  No Thank you. You are done. Please fax form to number shown above.

Instructions: Please provide the following information for every source of foods/beverages your school has other than vending machines and the cafeteria. If there is more than one of a given food source (for example, if there are multiple food carts) you can check more than one location per column and check off all the foods and beverages that are available in any of those locations.

	School Store	Snack Bar	Food Cart/Kiosk	Fundraiser	Other (Specify)
	Sells items in addition to foods/beverages; does not prepare/heat food	Sells only foods/beverages; prepares/heats some foods	Sells only foods/beverages; does not prepare/heat foods to order	Bake sale, candy drive, special pizza day, etc.	____________
1. Location Check the location(s) of each source
In cafeteria (including indoor and outdoor seating/eating area)	1 	NA	NA	1 	NA
Outside but near (within 20 feet) cafeteria or seating/eating area	2 	2 	2 	2 	2 
Elsewhere in school building(s)	3 	3 	3 	3 	3 
Outside school building(s), but on school grounds (not in seating/eating area)	4 	4 	4 	4 	4 
2. Beverages Check items available from each source
Diet carbonated soft drink (diet soda/pop)	5 	5 	5 	5 	5 
Regular carbonated soft drink (regular soda/pop)	6 	6 	6 	6 	6 
Juice (100% fruit or vegetable juice)	7 	7 	7 	7 	7 
Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	8 	8 	8 	8 	8 
Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)	9 	9 	9 	9 	9 
Bottled water (plain, flavored, or sparkling)	10 	10 	10 	10 	10 
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	11 	11 	11 	11 	11 
Flavored milk (such as chocolate or strawberry)	12 	12 	12 	12 	12 
Whole or reduced fat (2%) white milk	13 	13 	13 	13 	13 
Low-fat (1%) white milk	14 	14 	14 	14 	14 
Fat-free/skim white milk	15 	15 	15 	15 	15 
Other (Specify)	16 	16 	16 	16 	16 
Other (Specify)	17 	17 	17 	17 	17 

	School Store	Snack Bar	Food Cart/Kiosk	Fundraiser	Other (Specify)
	Sells items in addition to foods/beverages; does not prepare/heat food	Sells only foods/beverages; prepares/heats some foods	Sells only foods/beverages; does not prepare/heat foods to order	Bake sale, candy drive, special pizza day, etc.	____________
3. Snacks Check items available from each source
Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	18 	18 	18 	18 	18 
Regular chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	19 	19 	19 	19 	19 
Pretzels	20 	20 	20 	20 	20 
Popcorn	21 	21 	21 	21 	21 
Cracker sandwiches with cheese or peanut butter	22 	22 	22 	22 	22 
Other types of crackers (including animal crackers)	23 	23 	23 	23 	23 
Low-fat/reduced-fat granola bars, cereal bars, or energy bars	24 	24 	24 	24 	24 
Regular granola bars, cereal bars, or energy bars	25 	25 	25 	25 	25 
Crispy rice bars or treats	26 	26 	26 	26 	26 
Candy	27 	27 	27 	27 	27 
Gum	28 	28 	28 	28 	28 
Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)	29 	29 	29 	29 	29 
Fruit snacks (such as Fruit Roll-Ups or fruit leather)	30 	30 	30 	30 	30 
Meat snacks (such as jerky or pork rinds)	31 	31 	31 	31 	31 
Other (Specify)	32 	32 	32 	32 	32 
4. Baked Goods Check items available from each source
Low-fat/reduced-fat cakes, cupcakes, or brownies	33 	33 	33 	33 	33 
Regular cakes, cupcakes, or brownies	34 	34 	34 	34 	34 
Low-fat pies, turnovers, or toaster pastries	35 	35 	35 	35 	35 
Regular pies, turnovers, or toaster pastries	36 	36 	36 	36 	36 
Doughnuts	37 	37 	37 	37 	37 
Low-fat cookies	38 	38 	38 	38 	38 
Regular cookies	39 	39 	39 	39 	39 
Bread, rolls, bagels, or tortillas	40 	40 	40 	40 	40 
Other (Specify)	41 	41 	41 	41 	41 
5. Other Foods Check items available from each source
Yogurt	42 	42 	42 	42 	42 
Cheese	43 	43 	43 	43 	43 
Frozen fruit bars or popsicles	44 	44 	44 	44 	44 
Milkshakes, smoothies, or yogurt drinks	45 	45 	45 	45 	45 
Low-fat/reduced-fat ice cream, frozen yogurt, or sherbet	46 	46 	46 	46 	46 
Regular ice cream, frozen yogurt, or sherbet	47 	47 	47 	47 	47 
Dried fruit (such as raisins or apricots)	48 	48 	48 	48 	48 
Canned fruit	49 	49 	49 	49 	49 
Fresh fruit	50 	50 	50 	50 	50 
Vegetables	51 	51 	51 	51 	51 
Other (Specify)	52 	52 	52 	52 	52 

Prepared by Mathematica Policy Research, Inc. 2 Return completed form by fax to (609)799-0005 (Attn: Annalee Kelly)