Private Schools: 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 VERIFICATION FORM

FOR TARGET MONTH

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.

S FA: | | | | | | | | |

School: | | | | | | | | |

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

MONTH DAY YEAR

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

SCHOOL MEAL COUNT VERIFICATION FORM

FOR TARGET MONTH

A. Meal Counts for: Lunch |___| Breakfast |___| (USE ONE FORM PER EATING OCCASION)

A. PREVIOUS COMPLETED MONTH (IF ONLY KEEP WEEKLY RECORDS, GO TO B).

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

FOR A PROVISION 2 OR 3 SCHOOL OPERATING IN A NON-BASE YEAR OR A CEO SCHOOL, ENTER TOTAL COUNTS ONLY.

1. BREAKFAST COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

IF SCHOOL ALSO KEEPS WEEKLY RECORDS, COMPLETE SECTIONS “B”
THROUGH “F.” IF IT DOES NOT, GO TO SECTION G: STUDENT INFORMATION

B. FIRST WEEK OF PREVIOUS COMPLETED MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

C. SECOND WEEK OF PREVIOUS MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

D. THIRD WEEK OF PREVIOUS MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

E. FOURTH WEEK OF PREVIOUS MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

F. FIFTH WEEK OF PREVIOUS MONTH

From | | | / | | | / | | | to | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

1. BREAKFAST COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Breakfasts: | | |,| | | |,| | | |

2. LUNCH COUNT—TOTAL

1. Free: | | |,| | | |,| | | |

2. Reduced-Price: | | |,| | | |,| | | |

3. Paid (Full Price): | | |,| | | |,| | | |

4. Total Lunches: | | |,| | | |,| | | |

G. STUDENT INFORMATION FOR SCHOOL – TARGET MONTH

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

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

or | | | | %

IF SCHOOL IS PROVISION 2 OR 3 SCHOOL IN NON-BASE YEAR, SKIP TO SECTION H.

IF SCHOOL IS CEO SCHOOL, SKIP TO SECTION I.

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

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

H. PROVISION 2 OR 3 CLAIMING PERCENTAGES

COMPLETE ONLY FOR P2/3 SCHOOL IN NON-BASE YEAR

CLAIMING PERCENTAGES FOR BREAKFAST:

1. Free Meals | | | | PERCENT

2. Reduced-Price Meals | | | | PERCENT

3. Paid Meals | | | | PERCENT

4. Base Year Period Used:

Yearly Percentages 1

Monthly Percentages 2

Specify Month:

CLAIMING PERCENTAGES FOR LUNCH:

5. Free Meals | | | | PERCENT

6. Reduced-Price Meals | | | | PERCENT

7. Paid Meals | | | | PERCENT

8. Base Year Period Used:

Yearly Percentages 1

Monthly Percentages 2

Specify Month:

I. CEO SCHOOL CLAIMING PERCENTAGES

COMPLETE ONLY FOR CEO SCHOOL

A. CLAIMING PERCENTAGES FOR BREAKFAST:

1. Free Meals | | | | PERCENT

2. Paid Meals | | | | PERCENT

B. CLAIMING PERCENTAGES FOR LUNCH:

3. Free Meals | | | | PERCENT

4. Paid Meals | | | | PERCENT

Prepared by Mathematica Policy Research Page 0