State/Local: H - School Meal Count Verification Form

OMB Approval No.: 0584-0530

Approval Expires:

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY (APEC-II)

SCHOOL MEAL COUNT REPORTED TO SFA FOR

TARGET WEEK AND MONTH

SUPPLEMENTAL REPORTING FORM

(FOR SAMPLED SCHOOL)

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 collection is 0584-0530. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

SFA: | | | | |

School: | | | | |

Date: | | | / | | | / | | |

MONTH DAY YEAR

NSLP AND SBP ACCESS, PARTICIPATION, ELIGIBILITY, AND CERTIFICATION STUDY

(APEC-II)

SCHOOL MEAL COUNT REPORTED TO SFA FOR TARGET WEEK AND MONTH

SUPPLEMENTAL REPORTING FORM

(FOR SAMPLED SCHOOL)

COMPLETE THIS SUPPLEMENTAL REPORTING FORM IF THE SCHOOL USES A SECOND FORM TO SUBMIT MEAL COUNTS TO SFA’S. THAT IS, IF THE SCHOOL RECORDS MEALS COUNTS ONTO A FORM AND THEN TRANSFERS THE MEAL COUNTS FROM THAT FORM ONTO ANOTHER FORM AND SUBMITS THAT SECOND FORM TO THE SFA, THEN RECORD THE INFORMATION FROM THE FORM USED TO REPORT MEALS COUNTS TO THE SFA ON THIS “SUPPLEMENTAL REPORTING FORM.

INSTRUCTIONS: COMPLETE SECTIONS A-C FOR THE TARGET WEEK. THEN COMPLETE SECTIONS D-F IF SCHOOL KEEPS MONTHLY TOTALS, COMPLETE G-U IF SCHOOL KEEPS WEEKLY (BUT NOT MONTHLY) TOTALS.

IF CEO SCHOOL:

• ENTER REPORTED MEALS FOR FREE, PAID, AND TOTAL ONLY

• ENTER CLAIMING PERCENTAGES FOR FREE AND PAID ONLY

• DON’T INDICATE BASE PERIOD USED.

A. TARGET WEEK
from | | | / | | | / | | | to | | | / | | | / | | | MONTH DAY YEAR MONTH DAY YEAR
B. TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Breakfasts:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

C. TOTAL LUNCHES REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Breakfasts:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
D. PREVIOUS MONTH (IF ONLY KEEP WEEKLY RECORDS, GO TO G)
from | | | / | | | / | | | to | | | / | | | / | | | MONTH DAY YEAR MONTH DAY YEAR
E. TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Breakfasts:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
F. TOTAL LUNCHES REPORTED TO SFA
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Lunches:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

IF SCHOOL ALSO KEEPS WEEKLY RECORDS, COMPLETE PARTS “G” THROUGH “U.” IF SCHOOL ONLY KEEPS MONTHLY RECORDS, GO TO SECTION V, STUDENT INFORMATION
G. FIRST WEEK OF PREVIOUS MONTH
from | | | / | | | / | | | to | | | / | | | / | | | MONTH DAY YEAR MONTH DAY YEAR
H. TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Breakfasts:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
I. TOTAL LUNCHES REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Lunches:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

J. SECOND WEEK OF PREVIOUS MONTH
from | | | / | | | / | | | to | | | / | | | / | | | MONTH DAY YEAR MONTH DAY YEAR
K. TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Breakfasts:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
L. TOTAL LUNCHES REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Lunches:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

M. THIRD WEEK OF PREVIOUS MONTH
from | | | / | | | / | | | to | | | / | | | / | | | MONTH DAY YEAR MONTH DAY YEAR
N. TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Breakfasts:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

O. TOTAL LUNCHES REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Lunches:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

P. FOURTH WEEK OF PREVIOUS MONTH
from | | | / | | | / | | | to | | | / | | | / | | | MONTH DAY YEAR MONTH DAY YEAR
Q. TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Breakfasts:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
R. TOTAL LUNCHES REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Lunches:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

S. FIFTH WEEK OF PREVIOUS MONTH
from | | | / | | | / | | | to | | | / | | | / | | | MONTH DAY YEAR MONTH DAY YEAR
T. TOTAL BREAKFASTS REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Breakfasts:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:
U. TOTAL LUNCHES REPORTED TO SFA		IF PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR OR CEO SCHOOL, ENTER THE BASE YEAR CLAIMING PERCENTAGES
1. Free:	| | |,| | | |,| | | | | | | | PERCENT
2. Reduced-Price:	| | |,| | | |,| | | | | | | | PERCENT
3. Paid (Full Price):	| | |,| | | |,| | | | | | | | PERCENT
4. Total Lunches:	| | |,| | | |,| | | |
		BASE YEAR PERIOD USED:
		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH:

V. STUDENT INFORMATION—TARGET MONTH

1. Total number of enrolled students: | | | |,| | | |

2. Average daily attendance: | | | |,| | | |

or | | | | %

3. Number of serving days this month: | | |

FOR PROVISION 2 OR 3 SCHOOLS IN NON-BASE YEAR AND CEO SCHOOLS,
SKIP TO THE END.

4. Number of students approved for free meals: | | | |,| | | |

5. Number of students approved for reduced-price meals: | | | |,| | | |

Prepared by Mathematica Policy Research Page 0