Business Respondents

E3. Self-Administered Cost Questionnaire

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OMB Number: 0584-XXXX

Expiration Date: XX/XX/20XX

Study of Nutrition and Activity in Child Care Settings II

(SNACS-II)

Self-Administered Cost Questionnaire

This document should be completed by an administrator most familiar with food service/CACFP operations. Other agency personnel may need to assist in compiling information. [Please complete all pages before the SNACS-II visit to your site. / Please upload all pages to [SECURE TRANSFER SITE] by [DATE].]

Who completed this questionnaire?

Name: Title:

Phone: Email:

Organization:

Address:

Name: Title:

Phone: Email:

Organization:

Address:

The Food and Nutrition Service (FNS) is collecting this information to understand the nutritional quality of CACFP meals and snacks, the cost to produce them, and dietary intakes and activity levels of CACFP participants. This is a voluntary collection and FNS will use the information to examine CACFP operations. The collection does request personally identifiable information under the Privacy Act of 1974. Responses will be kept private to the extent provided by law and FNS regulations. 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 0.334 hours (20 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314. ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

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Please provide information on all CACFP activities. Sponsors, please provide information for CACFP activities for your organization. Independent Centers, please provide information for the sampled center only. For purposes of this questionnaire the term “organization” refers to the Sponsor organization or the Independent Center.

PART 1– PROGRAM DESCRIPTION

INDEPENDENT CENTERS: Please go to Part 2: Program Meal/Snack Information on the next page.

SPONSORS: Please continue to question 1 below.

1. SPONSORS ONLY: Now we are going to ask about the number of centers and/or programs that your organization sponsors broken down by age and type of center. Centers should be counted in each category for which they have children.

School-age includes Kindergarten but not Pre-K.

	Affiliated child care centers Select NA below if organization does not sponsor any affiliated centers NA 	Unaffiliated child care centers Select NA below if organization does not sponsor any unaffiliated centers NA 
a. What is the total number of centers/programs sponsored?
a1. How many are Head Start centers/programs?
a2. How many are other child care centers/programs (not Head Start)?
b. How many serve infants?
c. How many serve toddlers? (12 mo. – 36 mo.)
d. How many serve preschoolers? (36 mo. – Kindergarten entry)
e. How many serve both younger children and school-age children? School-age includes Kindergarten but not pre-K.
f. How many serve only school-age children? School-age includes Kindergarten but not pre-K.
g. What is the total number of family child care homes sponsored?
h. What is the total number of at-risk afterschool programs sponsored?
i. What is the total number of outside-school-hours care centers sponsored?

PART 2 – PROGRAM MEAL/SNACK INFORMATION

For the Federal Fiscal Year Oct. 1, 2021 – September 30, 2022 (FFY 2022), 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.

Sponsors: provide data for all sponsored centers and programs

Independent centers: provide data for the sampled child care center

2. Meal Counts

	A. Centers or sites serving infants, toddlers, or preschoolers, but 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 or Snack Type	# Paid	# Reduced price	# Free	# Paid	# Reducedprice	# Free	# Paid	# Reducedprice		# Free
Breakfast
Lunch
Supper
Snack

2a. If meal counts reported above are for any time period other than FFY 2022, please indicate the time period here:

__________________________________

PART 3 – SAMPLED CENTER/PROGRAM MEAL/SNACK INFORMATION

Please answer the following questions for the center/program listed on the cover of this booklet only.

3. How many days per year does this center/program serve children, while school is in session (i.e., school days)?

_______ DAYS WHILE SCHOOL IS IN SESSION

3a. Which CACFP meals are served by this center/program on school days?

CHECK ALL THAT APPLY

1 □ Breakfast

2 □ Morning Snack

3 □ Lunch

4 □ Afternoon Snack

5 □ Supper

4. How many days per year does this center/program serve children, when school is not in session (i.e., during school vacations or holidays)?

_______ DAYS WHILE SCHOOL IS NOT IN SESSION

4a. Which CACFP meals are served by this center/program on days when school is not in session?

CHECK ALL THAT APPLY

1 □ Breakfast

2 □ Morning Snack

3 □ Lunch

4 □ Afternoon Snack

5 □ Supper

5. We would like to know the number of children by age currently in your child care facility. We are looking for the average number of children in attendance per day for each age listed below. On an average day, how many children are at your facility in each of the following age categories?

[IF NECESSARY: If you cannot provide the average number of children in attendance per day for each age listed, we can also accept the number of children enrolled in your child care facility in each age category listed below.]

Age	Number of Children (RANGE: 0-999)
3a. Up to 3 months
3b. 4-5 months
3c. 6-7 months
3d. 8-11 months
3e. 1 year
3f. 2 years
3g. 3 years
3h. 4 years
3i. 5 years
3j. 6 years
3k. 7 years
3l. 8 years
3m. 9 years
3n. 10 years
3o. 11 years
3p. 12 years
3q. 13 years
3r. 14 years
3s. 15 years
3t. 16 years
3u. 17 years
3v. 18 years

PART 4 – MEAL AND SNACK COUNTS BOOKLET

This booklet contains two meal count forms: (1) Meal and Snack Counts Form (2) Infant Meal Counts Form.

The Meal and Snacks Counts Form should be used for children you serve age 1 and above.

The Infant Meal Counts Form should be used for infants you serve below 1 year of age.

The counts provided on these forms must be for the SAME week that the Menu Survey was completed for

The counts must be ONLY for the center/program listed on the cover of this booklet.

How to fill out the Meal and Snack Counts Form

Please provide the number of children served for each of the meals and snacks throughout the week indicated on the front cover.

• If your facility is closed for any of the days during the target week, mark it with an X over the day of the week.

• If you did not serve a meal or snack, please mark it with an X.

• The counts provided must be for the same week as the Menu Survey

Example of completed meal and snack counts form

In the example on the next page, the childcare facility does not serve dinner on Thursday, and the facility was closed on Friday.

EXAMPLE OF COMPLETED MEAL AND SNACK COUNTS FORM-MEALS ONLY

Number of Reimbursable Meals by Meal Type
Target Week			Total Number of Reimbursable Meals	For Admin Use
	Monday	Breakfast	26
		Lunch	24
		Dinner	23
	Tuesday	Breakfast	25
		Lunch	20
		Dinner	26
	Wednesday	Breakfast	21
		Lunch	23
		Dinner	26
	Thursday	Breakfast	26
		Lunch	24
		Dinner
	Friday	Breakfast
		Lunch
		Dinner

If you have any questions at any time please call our toll-free number at [STUDY PHONE]. We will be happy to answer your questions and to help you in any way we can.

Thank you very much for your help with this important study.

• Breakfast (start of care to 9am)

• Lunch (11am-1pm)

• Supper (4pm – 6pm)

• Morning Snack (9am – 11am)

• Afternoon Snack (1pm-4pm)

• Evening Snack (6pm until the child is picked up)

Meal and Snack Counts Form

Below, please provide the number of children served each meal and snack during the target week.

Number of Reimbursable Meals by Meal Type						Number of Reimbursable Snacks by Snack Type
Target Week			Total Number of Reimbursable Meals	For Admin Use		Target Week			Total Number of Reimbursable Snacks	For Admin Use
	Monday	Breakfast					Monday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack
	Tuesday	Breakfast					Tuesday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack
	Wednesday	Breakfast					Wednesday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack
	Thursday	Breakfast					Thursday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack
	Friday	Breakfast					Friday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack

How to fill out the Infant Meal Counts Form

The following instructions are only for child care providers participating in CACFP who prepare infant food, up to the age of 1.

Please provide the number of infants served on each day of the Target Week.

• If your facility is closed for any of the days during the target week, mark it with an X over the day of the week.

• The counts provided must be for the same week as the Menu Survey

Example of completed Infant Meal Counts Form

In this example, the childcare facility is closed on Friday.

Number of Infants Served Daily
Target Day		Total Number of Infants Served	For Admin Use
	Monday	10
	Tuesday	11
	Wednesday	10
	Thursday	11
	Friday

Infant Meal Counts Form

Please indicate the number of infants served in your childcare facility on each day of the target week.

Number of Infants Served Daily
Target Day		Total Number of Infants Served	For Admin Use
	Monday
	Tuesday
	Wednesday
	Thursday
	Friday

If you have any questions at any time please call our toll-free number at [STUDY PHONE]. We will be happy to answer your questions and to help you in any way we can.

Thank you very much for your help with this important study.

How to fill out the Meal and Snack Counts Supplement for Central and Production Kitchens

Please provide the total number of meals and snacks produced at your facility throughout the week indicated on the front cover.

• If your facility is closed for any of the days during the target week, mark it with an X over the day of the week.

• If you did not produce a meal or snack, please mark it with an X.

• The counts provided must be for the week indicated on the front cover.

Example of completed meal and snack counts form

In the example on the next page, the facility does not produce dinner on Thursday, and the facility was closed on Friday.

EXAMPLE OF COMPLETED MEAL AND SNACK COUNTS FORM-MEALS ONLY

Number of Reimbursable Meals by Meal Type
Target Week			Total Number of Reimbursable Meals	For Admin Use
	Monday	Breakfast	226
		Lunch	224
		Dinner	223
	Tuesday	Breakfast	225
		Lunch	220
		Dinner	226
	Wednesday	Breakfast	221
		Lunch	223
		Dinner	226
	Thursday	Breakfast	226
		Lunch	224
		Dinner
	Friday	Breakfast
		Lunch
		Dinner

If you have any questions at any time please call our toll-free number at [STUDY PHONE]. We will be happy to answer your questions and to help you in any way we can.

Thank you very much for your help with this important study.

• Breakfast (start of care to 9am)

• Lunch (11am-1pm)

• Supper (4pm – 6pm)

Meal and Snack Counts Supplement for Central and Production Kitchens

Below, please provide the total number of meals and snacks produced at your facility during the target week.

Number of Reimbursable Meals by Meal Type						Number of Reimbursable Snacks by Snack Type
Target Week			Total Number of Reimbursable Meals	For Admin Use		Target Week			Total Number of Reimbursable Snacks	For Admin Use
	Monday	Breakfast					Monday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack
	Tuesday	Breakfast					Tuesday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack
	Wednesday	Breakfast					Wednesday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack
	Thursday	Breakfast					Thursday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack
	Friday	Breakfast					Friday	Morning Snack
		Lunch						Afternoon Snack
		Dinner						Evening Snack

Authority: This information is being collected under the authority of the Healthy, Hunger-Free Kids Act of 2010 (P. L. 111-296), Section 305.

Purpose: The Food and Nutrition Service (FNS) is collecting this information to evaluate the nutritional quality of Child and Adult Care Food Program (CACFP) meals and snacks, the cost to produce them, and dietary intakes and activity levels of CACFP participants.

Routine Use: The records in this system may be disclosed to private firms that have contracted with FNS to collect, aggregate, analyze, or otherwise refine records for the purpose of research and reporting to Congress and appropriate oversight agencies, and/or departmental and FNS officials.

Disclosure: Disclosing the information is voluntary, and there are no consequences to you as an individual participant in the CACFP for not providing the information. 

The System of Records Notice for this information collection is USDA/FNS-8, FNS Studies and Reports, which can be located at https://www.govinfo.gov/content/pkg/FR-1991-04-25/pdf/FR-1991-04-25.pdf (p. 19078).