State, Local, and Tribal Government - State Child Nutrition Agency, SFA, and Schools

APPENDIX B9. SFA REIMBURSEMENT CLAIM VERIFICATION FORM—SAMPLED SCHOOLS

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

Third Access, Participation, Eligibility and Certification Study Series (APEC III)

SFA REIBURSEMENT CLAIM VERIFICATION FORM—SAMPLED SCHOOLS

SUMMARY:

The data collector will obtain and abstract meal count and claims data for the Target Month, which is the most recent calendar month in which meal count and claims data were submitted. In the rare instances in which the data for the Target Month is no longer available or accessible, the data collector will abstract data for the Target Week, which is the week prior to the data collection visit. In the even more rare instance in which the Target Week is not available, the data collector will collect the data for the Target Day, which is the day of the data collection visit.

Data will be entered into the SFA Reimbursement Claim Verification Form—Sampled Schools on the computer, saved, and securely transmitted to the home office.

SFA meal claim data will be used to determine aggregation errors at the SFA level.

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 0584-0530. The time required for the SFA data manager to provide access to the SFA claim records is estimated to average 30 minutes per response during each data collection round, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the collection of information.

COMPLETE ONE FORM PER SAMPLED SCHOOL

Number Serving Days:

Breakfast Lunch

| | | | | |

SFA Name:

SFA ID: |___|___|___|___|___|___|___|___|

School Name:

School ID: |___|___|___|___|___|___|___|___|

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

MONTH DAY YEAR

_________________________________________________________________________________________________

Select ONE (Target Month, Target Week, or Target Day):

 Target Month: | | | / | | || | |

MONTH YEAR

 Target Week: | | | / | | | / | | | TO | | | / | | | / | | |

MONTH DAY YEAR MONTH DAY YEAR

 Target Day | | | / | | | / | | |

MONTH DAY YEAR

IF CEP SCHOOL, ENTER “FREE”, “PAID” and “TOTAL” MEALS ONLY

PART A: BREAKFAST
REPORTED TO SFA BY SCHOOL					REPORTED TO STATE AGENCY BY SFA
Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |					Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
COMPLETE FOR PROVISION SCHOOL IN NON-BASE YEAR ENTER THE CLAIMING PERCENTAGES USED:					BASE YEAR PERIOD USED:
| | | | % FREE	| | | | % REDUCED		| | | | % PAID		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH USED:
COMPLETE FOR CEP SCHOOL ENTER THE CLAIMING PERCENTAGES USED:
				| | | | % FREE		| | | | % PAID
PART B: LUNCH
REPORTED TO SFA BY SCHOOL					REPORTED TO STATE AGENCY BY SFA
Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |					Free: | | | |,| | | | Reduced: | | | |,| | | | Paid: | | | |,| | | | Total: | | | |,| | | |
COMPLETE FOR PROVISION SCHOOL IN NON-BASE YEAR ENTER THE CLAIMING PERCENTAGES USED:					BASE YEAR PERIOD USED:
| | | | % FREE	| | | | % REDUCED		| | | | % PAID		YEARLY PERCENTAGES 1 MONTHLY PERCENTAGES 2 SPECIFY MONTH USED:
COMPLETE FOR CEP SCHOOL ENTER THE CLAIMING PERCENTAGES USED:
				| | | | % FREE		| | | | % PAID

PART C:

INTERVIEWER: The number of meals an SFA claims for a school may differ from what the schools report to the SFA because the SFA makes an error or because the SFA is correcting an error in the school’s meal counts.

1. COMPARE BREAKFAST COUNTS AND CLAIMS. First for breakfast, compare the SFA claims against the school reports for each meal type (free, reduced-price, paid, and total) for the target month. [Or for CEP schools, free, paid and total for the target month]. If they differ, then check the SFA records to see if there are any notes in the file indicating that the SFA corrected the school breakfast counts and document in the space provided below under “COMMENTS.”

Comparison Comments about BREAKFAST Counts and Claims:

2. COMPARE LUNCH COUNTS AND CLAIMS. Next for lunch, compare the SFA claims against the school reports for each meal type (free, reduced-price, paid, and total) for the target month. [Or for CEP schools, free, paid and total for the target month]. If they differ, then check the SFA records to see if there are any notes in the file indicating that the SFA corrected the school lunch counts and document in the space provided below under “COMMENTS.”

Comparison Comments about LUNCH Counts and Claims: