Businesses - Sponsors and Providers

F.2 Pre-Visit Cost Form

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OMB Control No: 0584-XXXX

OMB Approval Expiration Date: XX/XX/XXXX

Study of Nutrition and Activity in Child Care Settings (SNACS)

Pre-Visit Cost Form

Program/Respondent ID

Name: _________________________________

Title: __________________________________

Phone: (_____) _________________________

e-mail: _________________________________

Additional Respondent:

Name: _________________________________

Title: __________________________________

Phone: (_____) _________________________

e-mail: _________________________________

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 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.

About the Study. The Study of Nutrition and Activity in Child Care Settings is intended to study nutrition and activity in child care centers, family day care homes, afterschool programs, and at-risk programs participating in the Child and Adult Care Food Program (CACFP) and some not participating in the CACFP (We refer to all these settings as providers). More than 1,500 child care providers in over 20 states were selected to be part of the study. Abt Associates is conducting this study for the USDA Food and Nutrition Service (FNS). Participation in the study by selected sponsoring organizations (which we call sponsors) and child care providers who receive CACFP funds is required under Section 305 of the Healthy, Hunger-Free Kids Act of 2010 (HHFKA).

Data Collection Activity. The Pre-Visit Cost Form is intended to gather information on meal counts, revenues and expenses related to foodservice operations and the CACFP. It is expected to take respondents approximately 30 minutes to complete the form.

Protecting Privacy. All information gathered from child care sponsors, child care centers, family day care homes, child care administrators and staff, and families participating in this study is for research purposes only and will be kept private to the full extent allowed by law except for general geographic location. Responses will be grouped with those of other study participants, and no individual participants, program administrators, program staff, parents, or children will be identified in any study report. Being part of the study will not affect any USDA benefits received by programs or families participating in this data collection.

Questions. If you have any questions about the study please call our toll-free study number at 1-844-808-4777 or email XXXX@abtassoc.com. We will be happy to answer your questions and to help you in any way we can.

Thank you for participating in the Study of Nutrition and Activity in Child Care Settings.

STUDY ON NUTRITION AND ACTIVITY IN CHILD CARE SETTINGS PRE-VISIT COST FORM

This document should be completed by an administrator most familiar with foodservice/CACFP operations. Other agency personnel may need to assist in compiling information. Please return all pages by XX/XX/XX. This document may be mailed, faxed, or emailed to:

ADDRESS

FAX#

EMAIL

Please provide information on all CACFP activities (SPONSORS PROVIDE INFORMATION FOR CACFP ACTIVITIES FOR YOUR ORGANIZATION. INDEPENDENT CENTERS PROVIDE INFORMATION FOR THE SAMPLED CENTER). If you do not know certain information, please state this in the corresponding “Notes” section. Instructions for completing each section are included at the beginning of the section in italics.

This form includes the following sections:

1. Preliminary Foodservice Expense Statement

2. Preliminary Foodservice Revenue Statement

3. Annual CACFP Meal/Snack Counts

4. Total Organizational Revenues and Expenses, All Programs

5. Classroom Information

I. Preliminary Foodservice Expense Statement

For the most recent completed Federal Fiscal Year (Oct. 1, 2014 – September 30, 2015 (FFY 2015)), please complete the table below by entering amounts for each category of expenses. Child care centers should report CACFP expenses for the center; Sponsors should report CACFP expenses for the organization. Enter whole dollar amounts. We recognize that you might not track expenses in each category, however, please try and provide as much information as is available. See the definitions below. Explain what costs are included in the Notes column; if no costs available, enter NA. Definitions for all items are found on the page following the table.

• If expenses reported are for a time period other than FFY 2015, please indicate the time period here: __________________________________

Item	CACFP Costs	Notes
TOTAL LABOR
TOTAL OTHER DIRECT OPERATING COSTS
TOTAL EQUIPMENT PURCHASE AND DEPRECIATION COSTS (C1-C2)
TOTAL INDIRECT COSTS
TOTAL COSTS NOT LISTED ELSEWHERE
F. TOTAL FOOD
Total CACFP costs

The following are definitions of costs that should be included in the categories in the table above, to the extent that your organization has data available.

• A. LABOR – The total cost should include:

• Salaries and wages: Salaries and wages paid for time spent on foodservice and other CACFP activities by staff who prepare and serve food, record meal counts (e.g. cooks, teachers, etc.) and administrative personnel (e.g. director, finance officer, etc.). Does not include fees paid to independent consultants.

• Fringe benefits and payroll taxes: Cost of fringe benefits and taxes for foodservice and administrative personnel related to time spent on foodservice and the CACFP.

• B. OTHER DIRECT OPERATING COSTS – The total cost should include:

• Supplies and expendable equipment: The cost of non-food supplies and equipment purchases with a unit cost of less than $5,000 used to operate the CACFP (e.g. plates, utensils, copying/printing, microwave, etc.).

• Utilities: The cost of utilities used only for the operation of the CACFP.

• Rent: The cost of renting or leasing space, equipment, or vehicles used for the CACFP.

• Contracted services/interagency payments: Expenses for any contracted services used for administrative or operating function not performed by organization personnel (e.g. maintenance, professional services, insurance, etc.).

• Other miscellaneous direct operating costs

• C. EQUIPMENT PURCHASE AND DEPRECIATION COSTS – The total cost should include:

• Equipment purchase: Equipment purchases with a unit cost of $5,000 or more.

• Equipment depreciation: The annual depreciation cost related to equipment purchases with a unit cost of $5,000 or more.

• D. INDIRECT COSTS: The total cost should include the share of indirect costs attributable to the CACFP (if known). Indirect costs are those that have been incurred for common or joint objectives and cannot be readily identified or assigned to the foodservice, CACFP, other agency activities or components. Examples of common indirect costs are: leases of buildings and equipment used for common or joint objectives, costs of operating and maintaining facilities, salary of the receptionist, salary of central accounting staff, etc.

• F. FOOD: The cost of food purchased for meals served under the CACFP and USDA foods used in CACFP meals.
  
  

II. Preliminary Foodservice Revenue Statement

For FFY 2015, please complete the table below that contains the requested information. Child care centers should report CACFP revenues for the center; Sponsors should report CACFP revenues for the organization. Enter whole dollar amounts. Check “Not Applicable” if there is no revenue for the item. Add notes if information is not available or incomplete.

• If revenues reported are for a time period other than FFY 2015, please indicate the time period here: __________________________________

Item	Revenue	Not Applicable	Notes
CACFP reimbursement	$	
Child payments for meals	$	
Adult payments for meals	$	
Cash-in-lieu of USDA donated food	$	
Value of USDA donated food	$	
Other CACFP/ foodservice revenue	$	

Definitions:

• A. CACFP reimbursement: Reimbursement received from the State CACFP administering agency for eligible meals served to enrolled children, or for FDCH administration.

• B. Child payments for meals: Payments received from households to support the cost of meals served to children. If there is no separate charge for meals, report $0 on this line.

• C. Adult payments for meals: Payments received from staff/ other adults to support the cost of meals.

• D. Cash-in-lieu of USDA donated food: The value of credit received in lieu of the center’s entitlement to USDA foods.

• E. Value of USDA donated food: The value of USDA foods received, including USDA foods delivered to the center or sponsor and USDA foods received as part of processed products.

• F. Other CACFP/foodservice revenue: Any other income received to support foodservice operation, such as:

• Tuition, fees, or local, State, or Federal grant amounts specifically designated for foodservice program expenses

• Sale(s) of foodservice equipment purchased with CACFP funds

• Allowable interest earned on advance funds

• Proceeds from parent/child or other dinners

• Other CACFP/foodservice program income, such as the sale of materials developed using CACFP staff or resources

• Cash donations earmarked for the foodservice account

III. Annual CACFP Meal/Snack Counts

For the Federal Fiscal Year Oct. 1, 2014 – September 30, 2015 (FFY 2015), please provide counts of CACFP-eligible meals and snacks in the table below.

For centers or other sites that serve infants, toddlers, and/or preschoolers but no school-age children, put meal counts in Section A.

For centers or other sites that serve infants, toddlers, and/or preschoolers and also serve school-age children, put meal counts in Section B.

For centers or other sites that only serve school-age children, put meal counts in Section C.

and programs that serve school-age children only.

If meal counts reported are for any time period other than FFY 2015, please indicate the time period here: __________________________________

• Notes: ___________________________________________________________________

Sponsors: provide data for all sponsored centers and programs

Independent centers: provide data for the sampled child care center

	A. Centers or sites serving infants, toddlers, and/or preschoolers, no school-age children)				B. Centers or sites serving infants, toddlers, and/or preschoolers, and also school-age children)			C. Centers or sites serving only school-age children
	Total #:				Total #:			Total #:
Meal Type	# Paid	# Reduced price	# Free		# Paid	# Reduced price	# Free	# Paid	# Reduced price	# Free
Breakfast
Lunch
Supper
Snack

IV. Total Organizational Revenues and Expenses, All Programs

So that we can classify your agency for analysis purposes and analyze overhead costs, please complete the table below for the most recent completed Federal Fiscal Year (Oct. 1, 2014 – September 30, 2015 (FFY 2015)).

Please report total revenues and expenses for your organization, including revenues from child care and non-child care programs (e.g. parent fees, subsidy payments, etc.) and expenses from child care and non-child care programs (staff salaries/fringe, classroom supplies, etc.). Total revenues and expenses are generally reported on tax forms, profit/loss statements, and/or annual financial audits. If your available statement of expenses does not provide a total of personnel and/or non-personnel expenses, please report total expenses and attach a statement of expenses that provides information to compute personnel and non-personnel expenses.

• If total organizational revenues and expenses reported are for a time period other than FFY 2015, please indicate the time period here: __________________________________

Item	Total revenues and expenses for period	Notes
Total Revenues	$
B1. Total Personnel Expenses (salaries/wages, payroll taxes, and fringe benefits)	$
B2. Total Non-Personnel Expenses (all other direct and indirect/overhead costs excluding capital items)	$
B. Total Expenses	$

V. Classroom Information

Please complete the following information for each classroom/group of children in the sampled center or program named below. Sponsors may need to consult center directors to obtain this information. See the example below the table.

Name of Center/Program:_[prefilled information]______________________________________________________

Class Name/ Identifier	Age Range of Children	Open Time	Close Time	Breakfast Served?	Lunch Served?	Supper Served?	# of Snack times per day	Staff #1 Title	Staff #2 Title	Staff #3 Title
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N
				☐ Y ☐ N	☐ Y ☐ N	☐ Y ☐ N

Example:

Toddler 2

18-36 months

6:30am

5:30pm

☒ Y ☐ N

☒ Y ☐ N

☐ Y ☒ N

1

Teacher

Teacher Assistant

n/a

Thank you for completing this form. Please return by email to xxx@abtassoc.com or by fax to XXX-XXX-XXX.

Pre-Visit Cost Form, p. 1