SNMCS State, Local & Tribal Governments

K2. GROUPS 2, 3—SCHOOL STAFF LIAISON VENDING MACHINE FORM-ENHANCED

This page has been left blank for double-sided copying.

OMB Clearance Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Vending Machines

School year 2014-15

SCHOOL NUTRITION AND MEAL COST STUDY

Your Name:

Title:

Phone #:

School Name:

Date form was completed:

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 4 to enter information about any snack machines.

• If your school contains more than 25 beverage machines or more than 10 snack machines, please call (888) XXX-XXXX.

A ccording 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 information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 50 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

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 |______|
Whole or reduced fat (2%) flavored milk (such as chocolate)	19 |______|	19 |______|	19 |______|	19 |______|	19 |______|
Low-fat (1%) flavored milk (such as chocolate)	20 |______|	20 |______|	20 |______|	20 |______|	20 |______|
Fat-free/skim flavored milk (such as chocolate)	21 |______|	21 |______|	21 |______|	21 |______|	21 |______|
Whole or reduced fat (2%) white milk	22 |______|	22 |______|	22 |______|	22 |______|	22 |______|
Low-fat (1%) white milk	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Fat-free/skim white milk	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|
Other (Specify)	25 |______|	25 |______|	25 |______|	25 |______|	25 |______|
Other (Specify)	26 |______|	26 |______|	26 |______|	26 |______|	26 |______|

	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	22 |______|	22 |______|	22 |______|	22 |______|	22 |______|
Other (Specify)	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|

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	22 |______|	22 |______|	22 |______|	22 |______|	22 |______|
Other (Specify)	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|

	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	22 |______|	22 |______|	22 |______|	22 |______|	22 |______|
Other (Specify)	23 |______|	23 |______|	23 |______|	23 |______|	23 |______|
Other (Specify)	24 |______|	24 |______|	24 |______|	24 |______|	24 |______|

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	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 |______|
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 |______|

FREQUENTLY ASKED QUESTIONS

What if my school does not have any vending machines or other food sources?

It is important that we have a record of all the schools included in the study. Even if you have no vending machines or other food sources to report on, please complete each form by filling in the top part of the form with information about yourself and the school name, and checking off “No” in the box on the front page. Fax the entire form back to us.

What if I can’t complete these forms in the week you have specified?

Please call (888) 633-8329 or email xxxxx@mathematica-mpr.com to let us know when we should expect the returned forms.

What if a food item could be counted or checked in more than one category?

It is important not to count or check the same item in more than one place on the forms. Try to determine which category most closely describes the item and use that one. If you are unsure how to classify an item, put it in one of the ‘other’ spaces and specify what the item is.

What if I can’t tell which category to put a food or beverage in?

Some items might not clearly fit into one of the listed categories, especially if you can’t see the label. In these cases, use one of the ‘other’ spaces and specify what the item is.

What exactly should be counted in vending machines?

We are interested in knowing how many different selections can be made from a vending machine, even if some of those selections are for the same item. So, for a vending machine where you can see the items offered, you should count the “slots” holding the items. If the same cookies are in three different slots, each would be counted separately, since there are three different selections that will each get you cookies. Your counts should be based on the item that is in the front position of a slot. Do not count items behind the front position of a slot, regardless of whether these items are the same or different from what is in the front position. If a slot has no items at all or no item in the front position, it should be counted as empty.

For vending machines where you cannot see the items or their slots, you should count the buttons used to select the items instead. Each button should be counted separately, even if more than one button purchases the same item. If a button is marked as sold-out, it should be counted the same as an empty slot, and not counted on the form as an available item.

What if there is more than one of the same vending machine?

It is important that every vending machine available to students during the school day be reported separately. Some machines may be identical. But others may have subtle differences. For instance, one may be inside the cafeteria, while the other is just outside the cafeteria. Or one “Coke machine” might have two juice selections while another has only one and an empty slot.

What if a vending machine is out of order, is awaiting restocking, or has some other unusual circumstance?

Please call (888) xxx-xxxx or email xxxxx@mathematica-mpr.com to explain the situation and we will instruct you on how to proceed.

How can I tell the difference between a school store, snack bar, food cart/kiosk and fundraiser?

School Store: Sells pre-prepared or packaged food and beverages, as well as non-food items (like school supplies), but does not prepare or heat food; could be anywhere in the school, including within the cafeteria (or eating and seating area), but would still be run separately from the regular school food service.

Snack Bar: Prepares and/or heats foods to order (for example, sandwiches, hot dogs, French fries, etc.) separate from the regular cafeteria or food service area; located outside of the cafeteria (or eating and seating area); may include cafes, canteens, or concession stands.

Food Cart/Kiosk: Sells only pre-prepared or packaged food and beverages; does not prepare or heat foods to order or sell non-food items; located outside of the school cafeteria (or eating and seating area).

Fundraiser: Includes special sales such as bake sales, candy drives, or special pizza day to raise money for charity, field trips, band uniforms, or sending school teams to competitions.

If you are unsure of how to categorize a food or beverage source, please call (888) xxx-xxxx.

What if there is more than one food cart, snack bar, school store, or fundraiser?

In these situations, the form should be completed to include all items available from a given type of source, for example, all the items available from any of the food carts.

What if there was a recent fundraiser or bake sale, or one is coming up soon?

Only food sources that are available on the day you complete the forms should be included. Recent or future sources should not be included on the form.

Who can I contact if I have other questions about these forms?

If you have any questions about completing or returning the forms, please call (888) xxx-xxxx or email xxxxx@mathematica-mpr.com.