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pdfF02.01. MENU SURVEY (GROUP 2A, GROUP 3,
FULL OUTLYING AREAS)
Note to Reviewers: The burden statements for this instrument appear on
page 3 for Groups 2a and 3 and on page 33 for Group Full Outlying Areas
F02.01.01 INSTRUCTIONS FOR THE MENU SURVEY
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
This information is being collected to assist the Food and Nutrition Service in understanding school food purchasing practices, the
nutritional quality of school meals and snacks, the cost to produce school meals, and student participation and dietary intakes. This is a
mandatory collection and FNS will use the information to monitor program operations. This collection does not request any personally
identifiable information under the Privacy Act of 1974. 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 9 hours 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.
2024-2025 National School Foods
Study
Instructions for the
Menu Survey
Sponsored by:
U.S. Department of Agriculture
Food and Nutrition Service
INSTRUCTIONS FOR THE MENU SURVEY
INTRODUCTION FOR THE MENU SURVEY
Thank you for participating in the 2024-2025 National School Foods Study. Without
your help, and the help of school nutrition professionals like you across the country, this
important study could not be done.
As part of this study, you are being asked to complete a Menu Survey. The objective of
the Menu Survey is to obtain a complete and accurate description of the foods prepared
and served by your school nutrition program, including foods offered in reimbursable
meals and in afterschool snacks/suppers, as well as foods sold outside of reimbursable
meals. You will complete the survey forms during a specified time period, referred to as
the “target week.” The target week for your school is shown on the front of the Menu
Survey Folder.
The information you provide will be combined with information from many other schools
across the country and will be used to examine the food and nutrient content of school
meals and afterschool snacks, as well as foods sold outside of reimbursable meals. The
information you provide will also be used to estimate the cost of producing reimbursable
meals for the National School Lunch Program and School Breakfast Program.
This Instruction Manual describes the Menu Survey and provides easy-to-follow
instructions for completing the survey forms. Along with the manual is a set of sample
completed forms that may be useful when you are completing your own survey forms.
Be sure to look over the sample completed forms.
Below, we describe the forms included in the Menu Survey Folder. The rest of this manual
explains how to complete each form.
School Nutrition Manager Survey
We have included a survey that asks about school’s food service operations (white
paper). You can complete this survey on any day you would like and can even complete
it prior to the target week.
Daily Meal Counts Form
This one-page form (blue paper) is located behind the first tab inside the Menu Survey
Folder. This is a very simple form. All you have to do is write in the number of reimbursable
NSLP lunches and SBP breakfasts you served each day of the target week, by
reimbursement category. At the bottom of the form, you will record your non-program food
sales each day of the week or as a total across the week, by venue (if applicable).
Additional instructions are provided at the top of the form.
Reimbursable Foods Forms for Lunch and Breakfast
You will fill out these forms each day of the target week. They are located in colored
folders in the Menu Survey Folder labeled by day of the week (Monday forms, Tuesday
forms, etc.). There are separate forms for breakfast (yellow paper) and lunch (white
paper). You will use these forms to provide information about all foods and beverages
offered in reimbursable meals, including portion sizes; the number of portions prepared,
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INSTRUCTIONS FOR THE MENU SURVEY
served in reimbursable meals, sold a la carte or to adults, left over, and wasted; and the
food descriptions needed for an accurate nutrient analysis. You will also indicate whether
an item was a USDA Food or prepared from a recipe.
Recipe Forms
A booklet of Recipe Forms (grey paper) is located behind the “Recipes” tab in the Menu
Survey Folder. You will use the Recipe Forms to provide information on foods made by
combining two or more foods or ingredients during the target week. Alternatively, you can
provide printed copies of recipes instead of completing these forms.
Self-Serve/Made-to-Order Bar Form
Behind the next tab in the Menu Survey Folder is another booklet of forms (lavender
paper) for you to use to provide information about “self-serve” bars, such as salad bars
and condiment bars, as well as made-to-order bars such as deli bars. If your school offers
self-serve or made-to-order bars, you will use a Self-Serve/Made-to-Order Bar form to
describe the foods offered on each bar.
NSLP Afterschool Snack Form
If your school provides reimbursable snacks through the NSLP to one or more afterschool
programs, you will fill out the NSLP Afterschool Snack Form (green paper). You will
complete one form for each day that afterschool snacks are offered. These forms are
similar to but much simpler than the Reimbursable Foods Form.
CACFP Afterschool Snack and Supper Form
If your school provides reimbursable afterschool snacks or suppers through the Child and
Adult Care Food Program (CACFP) to one or more afterschool programs, you will fill out
the CACFP Afterschool Snack and Supper Form (green paper) to provide information
about the items provided in afterschool snacks and/or suppers each day. This includes
much of the same information you will be providing on the Reimbursable Foods Form.
Form for Non-Program Foods Sold by School Food Service
If your food service department sells non-program foods—that is, foods and beverages
that are sold to students only outside reimbursable meals—you will complete the Form
for Non-Program Foods Sold by School Food Service. This form is only for non-program
items sold in venues that are operated or stocked by your food service department. You
will use this form to provide information about all non-program foods and beverages,
including portion sizes, the number of items sold, and food descriptions needed for an
accurate nutrient analysis.
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INSTRUCTIONS FOR THE MENU SURVEY
The Rest of This Manual
The rest of this manual includes step-by-step instructions for completing each of the Menu
Survey forms. For each form, a completed sample form is provided. Please take the time
to review the instructions and all of the sample completed forms before beginning the
Menu Survey.
If You Need Assistance
We will be calling you before the start of the target week and again during the target week
to answer any questions you may have. If you have questions or need assistance at any
other time before, during, or after the target week, feel free to call or email our technical
assistants at [TA help line] or [TA email address]. Thank you for your assistance with
this important study!
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INSTRUCTIONS FOR MENU SURVEY
General Guidelines for
Completing the Menu Survey
Getting Started
Please read this manual carefully. Be sure to review the sample completed forms that are
provided.
Off-Site Kitchens
If your school receives prepared foods or meals or any components of reimbursable
meals from another school, a central kitchen, or an outside vendor during the target week,
we ask that you obtain food descriptions, product information, and recipes for these foods,
as needed. You may wish to discuss strategies for this task with your school food authority
(SFA) director.
If your schools prepare meals or foods to send off-site (either for reimbursable meals or
non-program foods), you will be asked to provide information on these items.
Filling Out Forms
✓ Use pencil on all forms.
✓ Write clearly and legibly (especially when recording numbers).
✓ Write the name of your school and the date (if applicable) at the top of each form.
✓ Double-check your work at the end of each day to be sure you have provided all
the necessary information.
At the End of the Week
When you have completed all forms included in the Menu Survey, please double-check
your work to make sure you have provided all the necessary information. Please place
the completed forms in the empty plastic envelope at the back of the Menu Survey Folder.
Remember to also include your completed School Nutrition Manager Survey. Return all
completed survey materials to Mathematica in the pre-addressed envelope
provided.
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INSTRUCTIONS FOR THE MENU SURVEY
Instructions for Completing the
Reimbursable Foods Forms
Purpose:
To describe foods and beverages that are offered as part of USDA
reimbursable lunches and breakfasts during the target week, and to provide
information on the number of portions of each item prepared, served in
reimbursable meals, sold a la carte/to adults, left over, and wasted (and
sent off-site, if applicable).
Location:
The Reimbursable Foods Forms are located in the five colored folders
labeled Monday-Friday, in the Menu Survey Folder. Separate forms are
provided for breakfast (yellow) and lunch (white).
Notes:
•
If your school offers reimbursable fruits and vegetables through the Fresh
Fruit and Vegetable Program during the target week, do NOT include these
fruits and vegetables on the Reimbursable Foods Form unless they are offered as
part of reimbursable lunches and breakfasts. If that is the case, be sure to report
only the portions that were prepared and served as part of reimbursable meals.
•
If your school offers meals to pre-kindergarten students, do NOT include any
foods that are offered only to these students and do NOT include the meals offered
to these students when reporting the number of reimbursable meals planned and
served each day.
•
Be sure to look at the sample completed Reimbursable Foods Forms that are
provided. Looking at the sample forms as you read the instructions will make it
easier to understand what you need to do when filling out the forms.
How to Complete the Reimbursable Foods Form
Reimbursable Meal Counts
On the top left-hand corner of the form, you will see the Reimbursable Meal Counts
box. The questions in this box ask about the number of reimbursable meals (breakfast or
lunch) you planned to serve for the day and the number of reimbursable meals that you
actually served that day. Record the answers to both questions in the spaces provided.
Your production records may include this information. If not, you may need to talk to your
SFA director to obtain it.
Column A: Food Item
You will use this column to identify foods and beverages offered in reimbursable meals
each day. Most foods are already listed for you. Others you will need to write in. In thinking
about all the foods offered in your cafeteria each day and deciding which ones to include
on this form, keep the following in mind:
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INSTRUCTIONS FOR THE MENU SURVEY
DO INCLUDE:
•
All foods and beverages offered in reimbursable meals (even if they may not count
toward USDA meal pattern requirements).
•
All condiments, salad dressings, optional toppings, desserts, and snack items.
DO NOT INCLUDE:
•
Foods and beverages that are sold only a la carte or only to adults. (Instead,
record these food and beverages on the Form for Non-Program Foods Sold by
Food Service.)
•
Foods and beverages that are offered and served only to pre-kindergarten
students.
•
Foods and beverages that were planned for a given day, but not actually prepared
at your school because a substitution was made.
When foods are paired or offered together:
When a bread/grain, meat/meat alternate, fruit, or vegetable offering is paired with, or
offered only with another menu item, add a note in Column A to make this clear.
Examples:
➢ For crackers that are offered only with a Chef’s salad, add a note…
Crackers w/ Chef’s salad
➢ For toast that is offered only with cereal, add a note…
Toast w/ cereal
➢ For a cheese stick that is offered only with a peanut butter
sandwich, add a note…
Cheese stick w/ peanut butter sandwich
➢ For blueberries that are offered only with pancakes, add a note…
Blueberries w/ pancakes
When writing in foods that are not already listed on the form:
•
Record foods in their appropriate food group sections whenever possible. Blank
lines are provided at the end of each section for your entries. A generous amount of
additional space is provided at the end of the form for recording items that do not fit
in the individual food group sections (for example, not enough blank lines for
additional fruits), as well as items that belong in a food group that is not listed on the
form.
•
Salad bars, condiment bars, and other food bars, whether self-serve or made-toorder, should be listed as single menu items. Salad bars (both side salad bars and
entrée salad bars) and other common theme bars are prelisted. Use separate lines
for any self-serve bars that are not prelisted.
•
If your school offers bag or box meals or fully preplated meals, write each type of
meal on a separate line. Complete a Recipe Form for each type of meal to identify
all of the foods and beverages included in the meal.
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INSTRUCTIONS FOR THE MENU SURVEY
If your school offers different foods to students in different grade groups:
•
Record each food offered separately and add a note in Column A to make it clear
which foods are offered to each grade group.
Example:
If your schools serves students in grades 6-8 and 9-12 and different entrées
are offered to each grade groups, you would indicate this by listing each food
separately and adding a note next to each food, as shown below.
A.
Food Item
Taco for grades 6-8
Burrito for grades 9-12
Column B: Portion Size
For each item offered in reimbursable meals, write the size of one individual serving, as
offered to students.
•
Include both the amount and the unit of measure (if not already printed on the
form). For example:
Food Item
Amount
Unit
Broccoli
¾
cup
Chicken patty
2.5
oz.
Tossed salad
½
cup
You may change the printed unit for any food if your school serves the item in a
different unit of measure.
•
Include the weight (oz.) of one portion whenever available, especially for
commercially prepared foods, such as burritos, chicken or fish nuggets, pizza,
doughnuts, or cookies.
•
For foods that are offered self-serve, write “self-serve” as the portion size.
•
If your school offers different portion sizes of the same food, for example to
students in two different grade groups, you will need to list the food twice (on two
separate lines) and write in the different portion sizes.
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INSTRUCTIONS FOR THE MENU SURVEY
Example:
If your school serves students in grades 6-8 and 9-12 and you offer different
portion sizes for canned peaches, you would indicate this by listing the food
twice and adding a note about which portion size applies to which grade group,
as shown below.
A.
B.
Portion Size
(Include
Units)
Food Item
Peaches, canned for grades 6-8
½ cup
Peaches, canned for grades 9-12
1 cup
Column C: Number of Portions
In the sub-columns under Column C, for each menu item, you will enter the total number
of portions prepared, and the number of portions sent off-site (if applicable), served to
students in reimbursable meals, sold a la carte or to adults/others, left over and saved for
later use, and wasted. Note that the number of portions entered in the last five subcolumns (Sent Off-Site, Reimbursable Served, Sold a La Carte or to Adults/Others, Left
Over for Later Use, and Wasted) should add up to the total number of portions prepared
(Total Prepared).
Total Portions Prepared
For each menu item, enter the total number of portions prepared. Include portions that
are prepared for reimbursable meals at your school as well as portions that are prepared
to be sent off-site (if applicable), sold a la carte and to adults/others. For pre-packaged
foods and beverages, the total number of portions prepared refers to the number of
individual packages that are put out in the serving area. For example, for cartons of juice,
write the number of cartons that are placed on the serving line before and throughout the
meal period.
Portions Sent Off-Site (if applicable)
If your school prepares food to be served at other schools or facilities, enter the total
number of portions for each item that is sent off-site. Include portions sent off-site on the
day they are sent – it doesn’t matter if they will be served on the same day or another
day. If your school does not prepare food to be served at other schools or facilities, you
do not need to complete this column.
Reimbursable Portions Served
For each menu item, enter the number of reimbursable portions served to students at
your school (excluding portions sold a la carte or to adults/others). Your production
records may include this information; if not, you may need to talk to your SFA director
about putting a procedure in place to record it for the target week. If a menu item is
prepared and available to students but none are served in reimbursable meals, be sure
to enter a zero in the Reimbursable Served column.
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INSTRUCTIONS FOR THE MENU SURVEY
Portions Sold A La Carte or to Adults/Others
Also, for each menu item, enter the number of portions that are sold a la carte, to adults,
or to others who are not receiving meals through the NSLP or SBP. If no portions are sold
a la carte or to adults/others, enter zero in this column. If the item was sold only to adults
(and not to any students), check the box “Only Sold to Adults” in this column.
Portions Left Over for Later Use
At the end of each meal, enter the number of portions that were not served on this day,
but were left over and may be served on a different day. For instance, this may include
cartons of milk or juice to be used on the following day. Do not include left over portions
that are thrown away. If no portions are left over and saved for later use, enter zero in this
column.
Portions Wasted
Also enter the number of portions that were not served and must be thrown out because
they cannot be used on a different day. For instance, this may include food prepared in a
large dish, such as macaroni and cheese. If no portions are wasted, enter zero in this
column.
Example:
Note that for each of the following menu items, the number of portions entered in
the last five sub-columns (Sent Off-Site, Reimbursable Served, Sold a La Carte or
to Adults/Others, Left Over, and Wasted) add up to the total number of portions
prepared (Total Prepared).
A.
B.
C.
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-site
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Orange juice
8 fl. oz.
140
0
120
10
Macaroni and
cheese
1 cup
200
20
160
0
Only
sold to
adults
Left Over
for Later
Use
Wasted
10
0
0
20
Column D: Manufacturer/Brand Name and Product Code
This column is used to provide information on the manufacturer, brand name, and product
code of certain foods listed in Column A. We have shaded this column for pre-listed foods
that do not require manufacturer/brand name, or a product code.
•
For all other commercially prepared food products you serve, including entrees,
meat/meat alternates, and most bread/grain items (including biscuits, doughnuts,
breakfast pastries, and pancakes), please fill in the manufacturer/brand and
product code information in Column D.
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INSTRUCTIONS FOR THE MENU SURVEY
•
Please do your best to record whatever manufacturer and/or brand information is
available (or at least how the food is described on the package label) for all
required foods. Always include a product code, if available. The product code is
usually located on the label of the box in which commercially prepared food
products are delivered. An example is shown below.
•
Below are additional examples of manufacturer and brand names, and products
codes, for some foods.
Food Item
(Column A)
Manufacturer/Brand Name
and Product Code (Column D)
Pizza, pepperoni
Super Donut
Pancake-on-a-stick
Schwan’s/Tony’s 78546
Super Bakery 6001
State Fair 70481
•
If your school purchases commercially prepared food products, including ones that
are lower in fat or sodium or include whole grains, you may wish to include package
labels to tell us more about the products. This will help ensure that the nutrient
analysis is accurate and reflects the types of foods used in your school meal
program.
•
If you decide that you would like to give us package labels, you can put them in
the envelope with the completed forms at the end of the week.
Column E: Food Description
This column is used to describe foods so that an accurate nutrient analysis can be done.
For most of the pre-listed items, you will need to check a box or write in a response. For
example, for some foods you will be asked to check whether a food is regular, low-fat or
fat-free, or if it is breaded or has icing. For some foods you will be asked to specify the
type or variety of the food, such as the type of bread (100% whole wheat, rye bread, etc.),
or the flavor of milk or yogurt.
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INSTRUCTIONS FOR THE MENU SURVEY
It is especially important to complete this column for commercially prepared products and
items that you add to the form. Please provide as complete a description of the item as
possible. Depending on the item, this may include information on:
✓
✓
✓
✓
✓
✓
type (100% whole wheat bread, rye bread, bean burrito)
form (fresh, frozen or canned vegetable or fruit)
flavor (strawberry milk, oatmeal cookie, vanilla yogurt)
fat content (low-fat yogurt, reduced-fat sour cream, fat-free salad dressing)
sugar content (sweetened, unsweetened, or reduced sugar)
sodium content (low-sodium green beans, reduced-sodium pizza)
Column F: Check Box if USDA Food
For food items in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column F.
Column G: Check Box if Prepared from a Recipe
For foods in Column A that are prepared from a recipe—that is, foods that are by
combining two or more foods or ingredients—place a check mark in Column G. Use these
checkmarks to remind you to complete a Recipe Form or provide a printed recipe.
We have shaded this column for pre-listed foods that do not require recipes. If the column
is not shaded, you may need a recipe, depending on the food. For example, for purchased
pizza that is served as is, a recipe is not needed. For pizza that is a modified version of a
purchased product (for example, you added your own toppings), a recipe is needed.
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INSTRUCTIONS FOR THE MENU SURVEY
Instructions for Completing the
Recipe Forms
Purpose:
To describe the types and amounts of ingredients used in preparing foods
made by combining two or more foods or ingredients.
Location:
A booklet of Recipe Forms (grey) is located behind the “Recipes” tab in the
Menu Survey Folder. If you need more forms than are included in the
booklet, make copies of the form and file the completed extra forms inside
the Recipe Form booklet.
Notes:
•
You may not have to fill out the Recipe Form if a printed copy of the recipe
is available. See the special instructions later in this section (page 14).
•
A recipe is needed for every item that is prepared by combining two or more
foods or ingredients. This includes all sandwiches and foods prepared or cooked
with added butter, margarine, dressings, or other condiments.
•
Some foods may need more than one Recipe Form. For example, for a tuna
salad sandwich, you will need to use two Recipe Forms—one for the tuna salad
mixture and one for the assembled tuna salad sandwich. The same is true for a
brownie or cake with icing. See the sample completed Recipe Forms for an
example of a situation where two Recipe Forms are needed.
•
If the same recipe was prepared more than once during the target week, you
only need to fill out a Recipe Form once and be sure to check the boxes at the top
of the form to indicate which days of the week the recipe was served, unless the
recipe is prepared differently on other days of the week. If variations of a recipe
are used on different days, a separate Recipe Form is needed for each variation.
•
Be sure to look at the sample completed Recipe Forms that are provided.
Looking at these forms as you read the instructions will make it easier to
understand what you need to do when filling out the form.
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INSTRUCTIONS FOR THE MENU SURVEY
How to Complete the Recipe Forms
Recipe/Food Name
Write the complete name of the recipe or food on the line provided in the upper righthand corner of the form. Please be sure that the name is clear enough that we will be
able to match it up with the appropriate item on the Reimbursable Foods Form.
For recipes that are used in other recipe items, mention both recipes in the name. For
example, “Tuna salad for tuna sandwich.”
Meal
Check the meal or meals in which the recipe/food item was offered.
Day
Check the day or days of the target week on which the recipe/food was offered. Check
“all” if the item is offered every day.
Size of One Serving
Write the size of one individual serving, as offered to students. Include both the amount
and unit of measure (Examples: 1/4 cup, 8 fluid ounces, 1 sandwich).
Number of Servings Prepared
Please record the total number of individual servings prepared (recipe yield) in the
space provided. For some items, such as sandwiches, the Recipe Form describes the
ingredients or components of a single serving (Examples: 1 sandwich, 1 Chef’s salad).
Column A: Ingredient Name
List all foods and ingredients used to prepare the recipe/food. Remember to include all
items used in food preparation, including seasonings and salt, as well as oils, butter,
margarine, and other fats used in cooking.
Column B: Amount in Recipe
For each item listed in Column A, write the amount used in Column B. Be sure to include
information on both the amount and the unit of measure (Examples: 2 Tbsp, 6 oz, 5
cups, 7.5 gallons, 35 lbs).
Be sure to provide amount information on the form of the ingredient when it was
measured. For example, was pasta or rice measured cooked or uncooked? Was meat
measured raw or after cooking? Was the cheese sliced, cubed, shredded, or grated?
Column C: Manufacturer/Brand Name and Product Code
If the ingredient or food listed in Column A is a commercially prepared food, list the
manufacturer and/or brand name as well as the product code.
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INSTRUCTIONS FOR THE MENU SURVEY
Column D: Ingredient Description
For each item listed in Column A, use this column to provide details about the food or
ingredient that will allow us to do an accurate nutrient analysis. Depending on the item,
this may include information on:
✓
✓
✓
✓
✓
✓
✓
type (whole wheat flour, brown rice, ground turkey)
form (fresh, frozen or canned vegetables, fruits, or meats)
cooking status (cooked, uncooked, dry, raw)
fat content (part-skim cheese, 1% fat milk, fat-free mayonnaise)
sodium content (low-sodium tomato sauce, reduced-sodium deli turkey)
sugar content (sweetened, unsweetened, or reduced sugar)
whether whole grain-rich
See the sample completed forms for examples of ingredient descriptions.
Column E: Check Box if USDA Food
For ingredients in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column E.
Column F: Check Box if Prepared from a Recipe
For ingredients in Column A that require a recipe, place a check mark in the appropriate
box in Column F. Use these checkmarks to remind you to complete an additional Recipe
Form.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
If You Can Provide a Printed Copy of the Recipe…
Be sure to:
•
Staple or clip a copy of the printed recipe to a blank Recipe Form in the booklet
and indicate on the Recipe Form the meal and days the recipe was used.
•
Mark the recipe, as needed, to show how the recipe was prepared in your school,
and make sure the name of the recipe matches the name used on the
Reimbursable Foods Form.
Make sure the recipe includes:
•
Yield information: size of one serving and number of servings prepared.
•
A complete description of all ingredients, including manufacturer and/or brand and
product code for commercially prepared food products.
•
An indication of any ingredients that are USDA Foods, for example, write “USDA”
beside the ingredient name.
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INSTRUCTIONS FOR THE MENU SURVEY
Instructions for Completing the Self-Serve/
Made-to-Order Bar Forms
Purpose:
To describe the ingredients included on self-serve bars such as salad bars,
theme bars, and condiment bars; made-to-order bars such as deli bars.
Location:
A booklet of Self-Serve/Made-to-Order Bar Forms (lavender) is located
behind the “Self-Serve Bars” tab in the Menu Survey Folder.
Notes:
•
A separate Self-Serve/Made-to-Order Bar Forms must be completed for each type
of self-serve bar or made-to-order bar offered. If the same bar was offered more
than once during the target week, you only need to fill out one Self-Serve/Madeto-Order Bar Forms and indicate the days on which the bar was offered. If the
foods/ingredients offered on the bar differ on other days of the week, a
separate form is needed for each day they are different.
•
Be sure to look at the sample completed Self-Serve/Made-to-Order Bar
Forms that are provided. Looking at these forms as you read the instructions will
make it easier to understand what you need to do when filling out the form.
How to Complete the Self-Serve/Made-to-Order Bar Forms
Name of Bar
Write the complete name of the self-serve/made-to-order bar on the line provided in the
upper right-hand corner of the form. Please be sure that the name is clear enough that
we will be able to match it up with the same item on the Reimbursable Foods Form.
Meal
Check the meal or meals in which the bar was offered during the target week.
Day
Check the day or days of the target week on which the bar was offered. Check “all” if the
bar (with all the same ingredients) is offered every day.
Column A: Food Name
List all foods and ingredients offered on the bar. If you need additional lines, write the
name of the bar and “continued” on a blank Self-Serve/Made-to-Order Bar Form and list
remaining foods/ingredients.
15
INSTRUCTIONS FOR THE MENU SURVEY
Column B: Portion Size (if pre-portioned)
For pre-portioned items only, describe the size of one portion. This includes items such
as baked potatoes, tortillas, packaged crackers, boxes of raisins, or packages of
sunflower seeds. It also includes items that might be portioned out by cafeteria servers,
such as pasta on a pasta bar, cold cuts on a deli bar, or meat and cheese items on a
salad bar.
Be sure to include information on both the amount and the unit of measure for preportioned items. See the sample completed Self-Serve/Made-to-Order Bar Forms for
examples.
Column C: Manufacturer/Brand Name and Product
For commercially prepared food products, please record the manufacturer and/or brand
name and a product code in Column C.
Column D: Food Description
For each item listed in Column A, use this column to provide details about the food or
ingredient that will allow us to do an accurate nutrient analysis. Depending on the item,
this may include information on:
✓ type (100% whole grain bread, rye bread, graham cracker, cheddar cheese,
deli turkey)
✓ form (fresh, frozen or canned vegetables or fruit)
✓ cooking status (cooked, uncooked, dry, raw)
✓ fat content (low-fat yogurt, reduced-fat sour cream, fat-free salad dressing)
✓ sodium content (low-sodium green beans, reduced-sodium deli turkey)
✓ whether whole grain-rich
See the sample completed forms for examples of ingredient descriptions.
Column E: Check Box if USDA Food
For foods in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column E.
Column F: Check Box if Prepared from a Recipe
For foods in Column A that require a recipe, place a check mark in the appropriate box
in Column F. Use these checkmarks to remind you to complete a Recipe Form.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
16
INSTRUCTIONS FOR THE MENU SURVEY
Instructions for Completing the
NSLP Afterschool Snack Form
Purpose:
To describe the foods and beverages offered in NSLP reimbursable
afterschool snacks during the target week, and to provide information on
the number of individual items prepared and served, as well as the total
number of reimbursable afterschool snacks served to students.
Location:
A booklet of NSLP Afterschool Snack Forms (green paper) is behind the
“NSLP Afterschool Snacks” tab in the Menu Survey Folder.
Notes:
•
Only include afterschool snacks offered through the National School
Lunch Program (NSLP). If your school offers snacks and/or suppers through
the Child and Adult Care Food Program (CACFP), you will complete the
CACFP Afterschool Snack and Supper Form.
•
If your school offers reimbursable fruits and vegetables through the
Fresh Fruit and Vegetable Program during the target week, do NOT include
these fruits and vegetables on the NSLP Afterschool Snack Form unless they
are offered as part of reimbursable afterschool snacks. If that is the case, be
sure to report only the portions that were prepared and served as part of
reimbursable afterschool snacks.
•
Be sure to look at the sample completed NSLP Afterschool Snack Form
that is provided. Looking at this sample as you read the instructions will make
it easier to understand what you need to do when filling out the form.
How to Complete the NSLP Afterschool Snack Form
On the front page of this booklet answer question 1 by indicating the days during the
target week that NSLP afterschool snacks were offered. Complete one NSLP Afterschool
Snack Form for each day snacks were offered.
This form is similar to the Reimbursable Foods Form. It includes columns for the food
item, portion sizes, the number of portions prepared/available and served, and the food
descriptions needed for an accurate nutrient analysis. You will also check if any item was
a USDA Food or prepared from a recipe. Depending on how your afterschool program
operates, you may need assistance from afterschool program staff to complete the
columns for number of portions served.
Day
Check the day of the target week for which this form is being completed.
17
INSTRUCTIONS FOR THE MENU SURVEY
Number of Reimbursable Snacks Served Onsite
At the top of the form, record the total number of reimbursable afterschool snacks served
to students at your school that day.
Column A: Food Item
You will use this column to identify foods and beverages offered in reimbursable NSLP
afterschool snacks each day. Some foods are already listed for you. Others you will
need to write in. In thinking about all the foods offered in your NSLP afterschool snacks
each day and deciding which to include on this form, keep the following in mind:
DO INCLUDE:
•
All foods and beverages offered in NSLP afterschool snacks (even if they may
not count toward USDA meal pattern requirements).
DO NOT INCLUDE:
•
Foods and beverages that are offered only to adults.
•
Foods and beverages that were planned for a given day, but not actually
prepared/available that day.
When writing in foods that are not already listed on the form:
•
Record foods in appropriate food group sections. Blank lines are provided at the
end of each section for your entries.
Column B: Portion Size
For each item offered in NSLP afterschool snacks, write the size of one individual serving,
as offered to students. If the snack item is pre-packaged, list the actual package size or
weight, not “1 package.”
•
Include both the amount and the unit of measure:
Food Item
•
Amount
Unit
Banana, fresh
1
cup
Orange juice
6
fl. oz.
Granola bar
1.5
oz.
If a food or beverage is offered in more than one portion size (for different grade
groups), list the food or beverage on separate lines and write in the different portion
sizes.
18
INSTRUCTIONS FOR THE MENU SURVEY
Example:
A.
B.
Food Item
(Include Units)
Portion Size
Orange juice
6 fl. oz.
Orange juice
8 fl. oz.
Column C: Number of Portions
In the sub-columns under Column C, for each afterschool snack item, you will enter the
total number of portions prepared/available, and the number of portions sent off-site (if
applicable), served to students in reimbursable afterschool snacks, left over and saved
for later use, and wasted. Note that the number of portions entered in the last four subcolumns (Sent Off-Site, Reimbursable Served, Left Over for Later Use, and Wasted)
should add up to the total number of portions prepared/available. You may need to ask
the afterschool program staff to provide some of this information. You can also give the
afterschool program staff a copy of the NSLP Afterschool Snack Form and ask them to
complete this column.
Total Portions Prepared/Available
For each afterschool snack item, write in the total number of portions prepared or
available to be served at your school. The total number of portions prepared/available
should reflect the actual number of servings available for students to select as part of a
reimbursable NSLP afterschool snack.
Sent Off-Site (if applicable)
If your school prepares foods to be served in NSLP afterschool snacks at other schools
or facilities, enter the number of portions of each afterschool snack item that are sent offsite.
Reimbursable Portions Served
Also, for each afterschool snack item, enter the number of reimbursable portions or
individual items served to (or selected by) students as part of a reimbursable NSLP
afterschool snack, excluding portions served to adults. If a menu item is prepared and
available to students but no portions are served, be sure to enter a zero in this column.
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INSTRUCTIONS FOR THE MENU SURVEY
Portions Left Over for Later Use
At the end of meal service, enter the number of portions that were not served on this day,
but were left over and may be served on a different day. For instance, this may include
cartons of milk or juice to be used on the following day. Do not include left over portions
that are thrown away. If no portions are left over and saved for later use, enter zero in this
column.
Portions Wasted
Also enter the number of portions that were not served and must be thrown out because
they cannot be used on a different day. For instance, this may include food that cannot
be served on another day, such as a sandwich. If no portions are wasted, enter zero in
this column.
Column D: Manufacturer/Brand Name and Product Code
This column is used to provide information on the manufacturer, brand name, and product
code of certain foods listed in Column A. We have shaded this column for pre-listed foods
that do not require manufacturer/brand name or a product code. For all other
commercially prepared food products you serve, please fill in the manufacturer/brand and
product code information in Column D.
Column E: Food Description
This column is used to describe foods so that an accurate nutrient analysis can be done.
For most of the pre-listed items, you will need to check a box or write in a response. For
example, for some foods you will be asked to check whether a food is regular, low-fat or
fat-free, or if it is whole grain-rich or reduced-fat. For some foods you will be asked to
specify the type or variety of the food, such as the type of crackers (graham, wheat,
saltines, etc.), or the flavor of milk or yogurt.
It is especially important to complete this column for commercially prepared products and
items that you add to the form. Please provide as complete a description of the item as
possible. Depending on the item, this may include information on:
✓
✓
✓
✓
type (1% milk; 100% whole wheat bread; blueberry muffin)
form (fresh, frozen or canned vegetable or fruit)
flavor (chocolate milk, strawberry yogurt)
fat content (low-fat yogurt, or fat-free salad dressing)
Column F: Check Box if USDA Food
For food items in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column F.
20
INSTRUCTIONS FOR THE MENU SURVEY
Column G: Check Box if Prepared from a Recipe
For foods in Column A that require a recipe, place a check mark in the appropriate box in
Column G. Use these checkmarks to remind you to complete a Recipe Form or provide
a printed recipe.
We have shaded this column for pre-listed foods that do not require recipes. If the column
is not shaded, you may need a recipe, depending on the food. For example, for purchased
pizza that is served as is, a recipe is not needed. For pizza that is a modified version of a
purchased product (for example, you added your own toppings), a recipe is needed.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
21
INSTRUCTIONS FOR THE MENU SURVEY
Instructions for Completing the
CACFP Afterschool Snack and Supper Form
Purpose:
To describe the foods and beverages offered in CACFP reimbursable
afterschool snacks and suppers during the target week, and to provide
information on the number of individual snack/supper items prepared and
served, as well as the total number of reimbursable snacks/suppers served
to students.
Location:
A booklet of CACFP Afterschool Snack and Supper Forms (green paper) is
behind the “CACFP Afterschool Snacks/Suppers” tab in the Menu Survey
Folder.
Notes:
•
Only include afterschool snacks and suppers offered through the Child
and Adult Care Food Program (CACFP). If your school offers afterschool
snacks through the National School Lunch Program (NSLP), you will complete
the NSLP Afterschool Snack Form.
•
If your school offers reimbursable fruits and vegetables through the
Fresh Fruit and Vegetable Program during the target week, do NOT include
these fruits and vegetables on the CACFP Afterschool Snack and Supper Form
unless they are offered as part of reimbursable afterschool snacks or suppers.
If that is the case, be sure to report only the portions that were prepared and
served as part of reimbursable afterschool snacks or suppers.
•
Be sure to look at the sample completed CACFP Afterschool Snack and
Supper Form that is provided. Looking at this sample as you read the
instructions will make it easier to understand what you need to do when filling
out the form.
How to Complete the CACFP Afterschool Snack and Supper Form
On the front page of this booklet answer question 1 by indicating the days during the
target week that CACFP afterschool snacks and/or suppers were offered. Complete one
CACFP Afterschool Snack and Supper Form for each day afterschool snacks and/or
suppers were offered.
This form is similar to the Reimbursable Foods Form. It includes columns for the food
item, portion sizes, the number of portions prepared/available and served, and the food
descriptions needed for an accurate nutrient analysis. You will also check if any item was
a USDA Food or prepared from a recipe. Depending on how your afterschool program
operates, you may need assistance from afterschool program staff to complete the
columns for number of portions served.
22
INSTRUCTIONS FOR THE MENU SURVEY
Day
Check the day of the target week for which this form is being completed.
Number of Reimbursable Snacks and/or Suppers Served Onsite
At the top of the form record the total number of CACFP reimbursable snacks and/or
suppers served to students at your school that day.
Column A: Food Item
You will use this column to identify foods and beverages offered in CACFP afterschool
snacks and/or suppers each day. Some foods are already listed for you. Others you will
need to write in. In thinking about all the foods offered in your afterschool snacks and/or
suppers each day and deciding which to include on this form, keep the following in
mind:
DO INCLUDE:
•
All foods and beverages offered in CACFP reimbursable afterschool snacks
and/or suppers (even if they may not count toward USDA meal pattern
requirements).
DO NOT INCLUDE:
•
Foods and beverages that are offered only to adults.
•
Foods and beverages that were planned for a given day, but not actually
prepared/available that day.
When writing in foods that are not already listed on the form:
•
Record foods in their appropriate food group sections whenever possible. Blank
lines are provided at the end of each section for your entries. A generous amount
of additional space is provided at the end of the form for recording items that do
not fit in the individual food group sections (for example, not enough blank lines
for additional fruits), as well as items that belong in a food group that is not listed
on the form.
Column B: Portion Size
For each item offered in CACFP afterschool snacks or suppers, write the size of one
individual serving, as offered to students. If the snack/supper item is pre-packaged, list
the actual package size or weight, not “1 package.”
23
INSTRUCTIONS FOR THE MENU SURVEY
•
Include both the amount and the unit of measure:
Food Item
Amount
Unit
1
cup
Orange juice
6
fl. oz.
Granola bar
1.5
oz.
Banana, fresh
•
If a food or beverage is offered in more than one portion size (for different grade
groups), list the food or beverage on separate lines and write in the different portion
sizes.
Example:
A.
B.
Food Item
(Include Units)
Portion Size
Orange juice
6 fl. oz.
Orange juice
8 fl. oz.
Column C: Number of Portions
In the sub-columns under Column C, for each afterschool snack or supper item, you will
enter the total number of portions prepared/available, and the number of portions sent
off-site (if applicable), served to students in reimbursable afterschool snacks/suppers, left
over and saved for later use, and wasted. Note that the number of portions entered in the
last four sub-columns (Sent Off-Site, Reimbursable Served, Left Over for Later Use, and
Wasted) should add up to the total number of portions prepared/available. You may need
to ask the afterschool program staff for this information. You can also give the afterschool
program staff a copy of the CACFP Afterschool Snack and Supper Form and ask them to
complete this column.
Total Portions Prepared/Available
For each afterschool snack/supper item offered, write in the total number of portions
prepared or available. The total number of portions prepared should reflect the actual
number of servings available for students at your school to select as part of a CACFP
snack or supper. If an item is prepared/available for both a snack and supper, write the
combined total.
Sent Off-Site (if applicable)
If your school prepares foods to be served in CACFP afterschool snacks/suppers at other
schools or facilities, enter the number of portions of each item that are sent off-site.
24
INSTRUCTIONS FOR THE MENU SURVEY
Reimbursable Portions Served
Also for each item, enter the number of reimbursable portions or individual items served
to (or selected by) students as part of a CACFP afterschool snack or supper, excluding
portions served to adults. If a menu item is prepared and available to students but no
portions are served, be sure to enter a zero in this column. If an item is served during
both an afterschool snack and supper, write the combined total.
Portions Left Over for Later Use
At the end of meal service, enter the number of reimbursable portions that were not
served on this day, but were left over and may be served on a different day. For instance,
this may include cartons of milk or juice to be used on the following day. Do not include
left over portions that are thrown away. If no portions are left over and saved for later use,
enter zero in this column.
Portions Wasted
Also enter the number of portions that were not served and must be thrown out because
they cannot be used on a different day. For instance, this may include food that has been
reheated and cannot be served on another day, such as pizza. If no portions are wasted,
enter zero in this column.
Column D: Manufacturer/Brand Name and Product Code
This column is used to provide information on the manufacturer, brand name, and product
code of certain foods listed in Column A. We have shaded this column for pre-listed foods
that do not require manufacturer/brand name, or a product code. For all other
commercially prepared food products you serve, please fill in the manufacturer/brand and
product code information in Column D.
Column E: Food Description
This column is used to describe foods so that an accurate nutrient analysis can be done.
For most of the pre-listed items, you will need to check a box or write in a response. For
example, for some foods you will be asked to check whether a food is regular, low-fat or
fat-free, or if it is whole grain-rich or reduced-fat. For some foods you will be asked to
specify the type or variety of the food, such as the type of crackers (graham, wheat,
saltines, etc.), or the flavor of milk or yogurt.
It is especially important to complete this column for commercially prepared products and
items that you add to the form. Please provide as complete a description of the item as
possible. Depending on the item, this may include information on:
✓
✓
✓
✓
type (1% milk; 100% whole wheat bread; blueberry muffin)
form (fresh, frozen or canned vegetable or fruit)
flavor (chocolate milk, strawberry yogurt)
fat content (low-fat yogurt, or fat-free salad dressing)
25
INSTRUCTIONS FOR THE MENU SURVEY
Column F: Check Box if USDA Food
For food items in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column F.
Column G: Check Box if Prepared from a Recipe
For foods in Column A that require a recipe, place a check mark in the appropriate box in
Column G. Use these checkmarks to remind you to complete a Recipe Form or provide
a printed recipe.
We have shaded this column for pre-listed foods that do not require recipes. If the column
is not shaded, you may need a recipe, depending on the food. For example, for purchased
pizza that is served as is, a recipe is not needed. For pizza that is a modified version of a
purchased product (for example, you added your own toppings), a recipe is needed.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
26
INSTRUCTIONS FOR THE MENU SURVEY
Instructions for Completing the Form for
Non-Program Foods Sold by School Food Service
Purpose:
To describe non-program foods and beverages that are sold only outside of
reimbursable meals and to provide information on the number of each item
sold—either each day of the target week or as a total across the week.
Notes:
•
Non-program foods include foods and beverages that are not offered as part of
reimbursable meals during the target week.
•
Include only non-program foods from venues that are operated or stocked
by your food service department, including foods sold on an a la carte-only basis
in cafeteria serving lines, in vending machines, snack bars, school stores, food
trucks, and food carts.
•
You will use one Form for Non-Program Foods Sold by School Food Service for
the target week. If you are providing information on number of each item sold each
day, you will leave the Weekly Total column blank. If you are providing information
on the number each item sold across the week, you will complete the Weekly Total
column only.
•
You may need to use your daily production records, storeroom inventory, front-ofthe-house stocking records, or ordering and inventory sheets for non-program
foods, if available, to help you fill out this form.
•
Be sure to look at the sample completed Form for Non-Program Foods Sold
by School Food Service that is provided. Looking at this sample as you read
the instructions will make it easier to understand what you need to do when filling
out the form.
How to Complete the Form for Non-Program Foods Sold by
School Food Service
Where Sold
Non-program foods may be sold on cafeteria serving lines or in other venues, such as
vending machines, snack bars, school stores, food trucks, food carts or at another
school or facility off-site. Indicate the venues where the non-program food items listed
on this form are sold, checking all boxes that apply. If the food service department sells
non-program foods in a venue that is not listed, check “Other,” and write in the name of
the venue.
27
INSTRUCTIONS FOR THE MENU SURVEY
Column A: Food Name
At the start of the target week, use this column to list all non-program items (foods and
beverages) that are sold across all venues operated or stocked by your food service
department. Creating a list of items at the start of the week will make the form easier to
fill out.
If an item is available in different flavors but the brand and package sizes are the same,
(for example, different flavors of 12 fl oz Izze Sparkling Juice®), you can list the items
once.
Column B: Portion Size
For each non-program food and beverage item, write the size of one individual serving,
as sold to students. Include both the amount and the unit of measure.
•
For items that are pre-packaged, record the actual package size, weight, or volume
(2.5 oz or 12 fl oz), not “1 package.”
•
For items prepared from recipes, write the size of one individual serving (“1/2 cup”
vanilla pudding) or simply the number of items offered (“1 sandwich,” “2 pieces,”
or “1 each”).
•
If a food or beverage item is sold in more than one portion size, list the item more
than once, on separate lines for each portion size.
A.
B.
Portion Size
(Include Units)
Food Item
Crackers
0.75 oz
Crackers
1.0 oz
Column C: Manufacturer/Brand Name and Product Code
For commercially prepared or pre-packaged items that are not prepared from a recipe,
please record the manufacturer/brand name and a product code (if available) in Column
C. Below are examples of manufacturer/brand names and products codes for some
foods.
A.
C.
Food Item
Manufacturer/Brand Name and Product Code
Pretzels
Snyder’s of Hanover, Item 107641
Corndog
Foster Farms, Code 94124
Cheese breadstick or pizza stick
Bosco’s Pizza Co, Code 2672
Column D: Food Description
For each item listed in Column A, use this column to provide details about the type or
28
INSTRUCTIONS FOR THE MENU SURVEY
variety of the food. Please provide as complete a description of the item as possible.
Depending on the item, this may include information on:
✓
✓
✓
✓
✓
✓
type: (blueberry muffin, bean burrito or turkey sandwich)
form (fresh, frozen or canned vegetable or fruit)
flavor (strawberry milk, oatmeal cookie or vanilla yogurt)
fat content (low-fat yogurt, reduced-fat sour cream, or fat-free salad dressing)
sugar content (sweetened, unsweetened, or reduced sugar)
sodium content (low-sodium vegetable juice or reduced-sodium pizza)
If an item is available in different flavors or varieties indicate this in Column D (Food
Description).
Column E: Check Box if Whole Grain-Rich
For food items in Column A that are whole grain-rich, place a check mark in the box in
Column E.
Column F: Check Box if Prepared from a Recipe
If an item was prepared from a recipe, check the box in Column F. Use these
checkmarks to remind you to complete a Recipe Form or provide a printed recipe.
Remember that recipes are needed for all items that are made by combining two or
more foods or ingredients.
Column G: Number of Portions Sold
If you are providing information on number of portions of each item sold each day of the
target week, complete the number of portion columns for each day, and leave the Weekly
Total column blank. If you are providing information on the number of portions sold
across the week, complete only the Weekly Total column (and leave each day’s column
blank).
For all non-program items, enter the total number of portions sold that day, or over the
week if providing number of portions sold across the week. If an item is offered but none
are sold, be sure to enter zero.
Sent Off-Site (if applicable)
If your school sends any non-program foods or beverages to other schools or facilities,
include the number of portions of each item that are sent off-site in the Sent Off-Site
column. Include the total portions of each item that are sent off-site across the week.
Column H: Availability
For each item listed in Column A, use this column to indicate whether the food or
beverage was available for students to purchase during breakfast, during lunch, and/or
outside of meal periods. If the item was available during more than one meal period or at
any time throughout the school day, select all options that apply.
29
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
This information is being collected to assist the Food and Nutrition Service in understanding school food purchasing practices, the
nutritional quality of school meals and snacks, the cost to produce school meals, and student participation and dietary intakes.
This is a mandatory collection and FNS will use the information to monitor program operations. This collection does not request
any personally identifiable information under the Privacy Act of 1974. 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 9 hours 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.
2024-2025 National School
Foods Study
Instructions for the
Menu Survey
(For Alaska, Hawaii and
Guam)
Sponsored by:
U.S. Department of Agriculture
Food and Nutrition Service
This page has been left blank for double-sided copying.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
INTRODUCTION FOR THE MENU SURVEY
Thank you for participating in the 2024-2025 National School Foods Study. Without
your help, and the help of school nutrition professionals like you in the outlying areas, this
important study could not be done.
As part of this study, you are being asked to complete a Menu Survey. The objective of
the Menu Survey is to obtain a complete and accurate description of the foods prepared
and served by your school nutrition program, including foods offered in reimbursable
meals, as well as foods sold outside of reimbursable meals. You will complete the survey
forms during a specified time period, referred to as the “target week.” The target week for
your school is shown on the front of the Menu Survey Folder.
The information you provide will be used to estimate the cost of producing reimbursable
meals for the National School Lunch Program and School Breakfast Program. This study
is important because an accurate assessment of meal costs could eventually be used to
adjust per-meal reimbursement rates in outlying areas.
This Instruction Manual describes the Menu Survey and provides easy-to-follow
instructions for completing the survey forms. Along with the manual is a set of sample
completed forms that may be useful when you are completing your own survey forms.
Be sure to look over the sample completed forms.
Below, we describe the forms included in the Menu Survey Folder. The rest of this manual
explains how to complete each form.
Daily Meal Counts Form
This one-page form (blue paper) is located behind the first tab inside the Menu Survey
Folder. This is a very simple form. All you have to do is write in the number of reimbursable
NSLP lunches and SBP breakfasts you served each day of the target week, by
reimbursement category. At the bottom of the form, you will record your non-program food
sales each day of the week or as a total across the week, by venue (if applicable).
Additional instructions are provided at the top of the form.
Reimbursable Foods Forms for Lunch and Breakfast
You will fill out these forms each day of the target week. They are located in colored
folders in the Menu Survey Folder labeled by day of the week (Monday forms, Tuesday
forms, etc.). There are separate forms for breakfast (yellow paper) and lunch (white
paper). You will use these forms to provide information about all foods and beverages
offered in reimbursable meals, including portion sizes; the number of portions prepared,
served in reimbursable meals, sold a la carte or to adults, left over, and wasted; and
detailed food descriptions. You will also indicate whether an item was a USDA Food or
prepared from a recipe.
Recipe Forms
A booklet of Recipe Forms (grey paper) is located behind the “Recipes” tab in the Menu
Survey Folder. You will use the Recipe Forms to provide information on foods made by
1
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
combining two or more foods or ingredients during the target week. Alternatively, you can
provide printed copies of recipes instead of completing these forms.
Self-Serve/Made-to-Order Bar Form
Behind the next tab in the Menu Survey Folder is another booklet of forms (lavender
paper) for you to use to provide information about “self-serve” bars, such as salad bars
and condiment bars, as well as made-to-order bars such as deli bars. If your school offers
self-serve or made-to-order bars, you will use a Self-Serve/Made-to-Order Bar form to
describe the foods offered on each bar.
Form for Non-Program Foods Sold by School Food Service
If your food service department sells non-program foods—that is, foods and beverages
that are sold to students only outside reimbursable meals—you will complete the Form
for Non-Program Foods Sold by School Food Service. This form is only for non-program
items sold in venues that are operated or stocked by your food service department. You
will use this form to provide information about all non-program foods and beverages,
including portion sizes, the number of items sold, and food descriptions.
The Rest of This Manual
The rest of this manual includes step-by-step instructions for completing each of the Menu
Survey forms. For each form, a completed sample form is provided. Please take the time
to review the instructions and all of the sample completed forms before beginning the
Menu Survey.
If You Need Assistance
We will be calling you before the start of the target week and again during the target week
to answer any questions you may have. If you have questions or need assistance at any
other time before, during, or after the target week, feel free to call or email our technical
assistants at [TA help line] or [TA email address]. Thank you for your assistance with
this important study!
INSTRUCTIONS FOR THE MENU SURVEY (FULL OUTLYING, AREAS)
General Guidelines for
Completing the Menu Survey
Getting Started
Please read this manual carefully. Be sure to review the sample completed forms that are
provided.
Off-Site Kitchens
If your school receives prepared foods or meals or any components of reimbursable
meals from another school, a central kitchen, or an outside vendor during the target week,
we ask that you obtain food descriptions, product information, and recipes for these foods,
as needed. You may wish to discuss strategies for this task with your school food authority
(SFA) director.
If your schools prepare meals or foods to send off-site (either for reimbursable meals or
non-program foods), you will be asked to provide information on these items.
Filling Out Forms
✓ Use pencil on all forms.
✓ Write clearly and legibly (especially when recording numbers).
✓ Write the name of your school and the date (if applicable) at the top of each form.
✓ Double-check your work at the end of each day to be sure you have provided all
the necessary information.
At the End of the Week
When you have completed all forms included in the Menu Survey, please double-check
your work to make sure you have provided all the necessary information. Please place
the completed forms in the empty plastic envelope at the back of the Menu Survey Folder.
Return all completed survey materials to Mathematica in the pre-addressed
envelope provided.
4
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
Instructions for Completing the
Reimbursable Foods Forms
Purpose:
To describe foods and beverages that are offered as part of USDA
reimbursable lunches and breakfasts during the target week, and to provide
information on the number of portions of each item prepared, served in
reimbursable meals, sold a la carte/to adults, left over, and wasted (and
sent off-site, if applicable).
Location:
The Reimbursable Foods Forms are located in the five colored folders
labeled Monday-Friday, in the Menu Survey Folder. Separate forms are
provided for breakfast (yellow) and lunch (white).
Notes:
•
If your school offers reimbursable fruits and vegetables through the Fresh
Fruit and Vegetable Program during the target week, do NOT include these
fruits and vegetables on the Reimbursable Foods Form unless they are offered as
part of reimbursable lunches and breakfasts. If that is the case, be sure to report
only the portions that were prepared and served as part of reimbursable meals.
•
If your school offers meals to pre-kindergarten students, do NOT include any
foods that are offered only to these students and do NOT include the meals offered
to these students when reporting the number of reimbursable meals planned and
served each day.
•
Be sure to look at the sample completed Reimbursable Foods Forms that are
provided. Looking at the sample forms as you read the instructions will make it
easier to understand what you need to do when filling out the forms.
How to Complete the Reimbursable Foods Form
Reimbursable Meal Counts
On the top left-hand corner of the form, you will see the Reimbursable Meal Counts
box. The questions in this box ask about the number of reimbursable meals (breakfast or
lunch) you planned to serve for the day and the number of reimbursable meals that you
actually served that day. Record the answers to both questions in the spaces provided.
Your production records may include this information. If not, you may need to talk to your
SFA director to obtain it.
Column A: Food Item
You will use this column to identify foods and beverages offered in reimbursable meals
each day. Most foods are already listed for you. Others you will need to write in. In thinking
about all the foods offered in your cafeteria each day and deciding which ones to include
on this form, keep the following in mind:
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
DO INCLUDE:
•
All foods and beverages offered in reimbursable meals (even if they may not count
toward USDA meal pattern requirements).
•
All condiments, salad dressings, optional toppings, desserts, and snack items.
DO NOT INCLUDE:
•
Foods and beverages that are sold only a la carte or only to adults. (Instead,
record these food and beverages on the Form for Non-Program Foods Sold by
Food Service.)
•
Foods and beverages that are offered and served only to pre-kindergarten
students.
•
Foods and beverages that were planned for a given day, but not actually prepared
at your school because a substitution was made.
When foods are paired or offered together:
When a bread/grain, meat/meat alternate, fruit, or vegetable offering is paired with, or
offered only with another menu item, add a note in Column A to make this clear.
Examples:
➢ For crackers that are offered only with a Chef’s salad, add a note…
Crackers w/ Chef’s salad
➢ For toast that is offered only with cereal, add a note…
Toast w/ cereal
➢ For a cheese stick that is offered only with a peanut butter
sandwich, add a note…
Cheese stick w/ peanut butter sandwich
➢ For blueberries that are offered only with pancakes, add a note…
Blueberries w/ pancakes
When writing in foods that are not already listed on the form:
•
Record foods in their appropriate food group sections whenever possible. Blank
lines are provided at the end of each section for your entries. A generous amount of
additional space is provided at the end of the form for recording items that do not fit
in the individual food group sections (for example, not enough blank lines for
additional fruits), as well as items that belong in a food group that is not listed on the
form.
•
Salad bars, condiment bars, and other food bars, whether self-serve or made-toorder, should be listed as single menu items. Salad bars (both side salad bars and
entrée salad bars) and other common theme bars are prelisted. Use separate lines
for any self-serve bars that are not prelisted.
•
If your school offers bag or box meals or fully preplated meals, write each type of
meal on a separate line. Complete a Recipe Form for each type of meal to identify
all of the foods and beverages included in the meal.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
If your school offers different foods to students in different grade groups:
•
Record each food offered separately and add a note in Column A to make it clear
which foods are offered to each grade group.
Example:
If your schools serves students in grades 6-8 and 9-12 and different entrées
are offered to each grade groups, you would indicate this by listing each food
separately and adding a note next to each food, as shown below.
A.
Food Item
Taco for grades 6-8
Burrito for grades 9-12
Column B: Portion Size
For each item offered in reimbursable meals, write the size of one individual serving, as
offered to students.
•
Include both the amount and the unit of measure (if not already printed on the
form). For example:
Food Item
Amount
Unit
Broccoli
¾
cup
Chicken patty
2.5
oz.
Tossed salad
½
cup
You may change the printed unit for any food if your school serves the item in a
different unit of measure.
•
Include the weight (oz.) of one portion whenever available, especially for
commercially prepared foods, such as burritos, chicken or fish nuggets, pizza,
doughnuts, or cookies.
•
For foods that are offered self-serve, write “self-serve” as the portion size.
•
If your school offers different portion sizes of the same food, for example to
students in two different grade groups, you will need to list the food twice (on two
separate lines) and write in the different portion sizes.
Example:
If your school serves students in grades 6-8 and 9-12 and you offer different
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
portion sizes for canned peaches, you would indicate this by listing the food
twice and adding a note about which portion size applies to which grade group,
as shown below.
A.
Food Item
B.
Portion Size
(Include
Units)
Peaches, canned for grades 6-8
½ cup
Peaches, canned for grades 9-12
1 cup
Column C: Number of Portions
In the sub-columns under Column C, for each menu item, you will enter the total number
of portions prepared, and the number of portions sent off-site (if applicable), served to
students in reimbursable meals, sold a la carte or to adults/others, left over and saved for
later use, and wasted. Note that the number of portions entered in the last five subcolumns (Sent Off-Site, Reimbursable Served, Sold a La Carte or to Adults/Others, Left
Over for Later Use, and Wasted) should add up to the total number of portions prepared
(Total Prepared).
Total Portions Prepared
For each menu item, enter the total number of portions prepared. Include portions that
are prepared for reimbursable meals at your school as well as portions that are prepared
to be sent off-site (if applicable), sold a la carte and to adults/others. For pre-packaged
foods and beverages, the total number of portions prepared refers to the number of
individual packages that are put out in the serving area. For example, for cartons of juice,
write the number of cartons that are placed on the serving line before and throughout the
meal period.
Portions Sent Off-Site (if applicable)
If your school prepares food to be served at other schools or facilities, enter the total
number of portions for each item that is sent off-site. Include portions sent off-site on the
day they are sent – it doesn’t matter if they will be served on the same day or another
day. If your school does not prepare food to be served at other schools or facilities, you
do not need to complete this column.
Reimbursable Portions Served
For each menu item, enter the number of reimbursable portions served to students at
your school (excluding portions sold a la carte or to adults/others). Your production
records may include this information; if not, you may need to talk to your SFA director
about putting a procedure in place to record it for the target week. If a menu item is
prepared and available to students but none are served in reimbursable meals, be sure
to enter a zero in the Reimbursable Served column.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
Portions Sold A La Carte or to Adults/Others
Also, for each menu item, enter the number of portions that are sold a la carte, to adults,
or to others who are not receiving meals through the NSLP or SBP. If no portions are sold
a la carte or to adults/others, enter zero in this column. If the item was sold only to adults
(and not to any students), check the box “Only Sold to Adults” in this column.
Portions Left Over for Later Use
At the end of each meal, enter the number of portions that were not served on this day,
but were left over and may be served on a different day. For instance, this may include
cartons of milk or juice to be used on the following day. Do not include left over portions
that are thrown away. If no portions are left over and saved for later use, enter zero in this
column.
Portions Wasted
Also enter the number of portions that were not served and must be thrown out because
they cannot be used on a different day. For instance, this may include food prepared in a
large dish, such as macaroni and cheese. If no portions are wasted, enter zero in this
column.
Example:
Note that for each of the following menu items, the number of portions entered in
the last five sub-columns (Sent Off-Site, Reimbursable Served, Sold a La Carte or
to Adults/Others, Left Over, and Wasted) add up to the total number of portions
prepared (Total Prepared).
A.
B.
C.
Number of Portions
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
Off-site
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Orange juice
8 fl. oz.
140
0
120
10
Macaroni and
cheese
1 cup
200
20
160
0
Only
sold to
adults
Left Over
for Later
Use
Wasted
10
0
0
20
Column D: Manufacturer/Brand Name and Product Code
This column is used to provide information on the manufacturer, brand name, and product
code of certain foods listed in Column A. We have shaded this column for pre-listed foods
that do not require manufacturer/brand name, or a product code.
•
For all other commercially prepared food products you serve, including entrees,
meat/meat alternates, and most bread/grain items (including biscuits, doughnuts,
breakfast pastries, and pancakes), please fill in the manufacturer/brand and
product code information in Column D.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
•
Please do your best to record whatever manufacturer and/or brand information is
available (or at least how the food is described on the package label) for all
required foods. Always include a product code, if available. The product code is
usually located on the label of the box in which commercially prepared food
products are delivered. An example is shown below.
•
Below are additional examples of manufacturer and brand names, and products
codes, for some foods.
Food Item
(Column A)
Manufacturer/Brand Name
and Product Code (Column D)
Pizza, pepperoni
Super Donut
Pancake-on-a-stick
Schwan’s/Tony’s 78546
Super Bakery 6001
State Fair 70481
•
If your school purchases commercially prepared food products, including ones that
are lower in fat or sodium or include whole grains, you may wish to include package
labels to tell us more about the products.
•
If you decide that you would like to give us package labels, you can put them in
the envelope with the completed forms at the end of the week.
Column E: Food Description
This column is used to provide detailed descriptions of foods. For most of the pre-listed
items, you will need to check a box or write in a response. For example, for some foods
you will be asked to check whether a food is regular, low-fat or fat-free, or if it is breaded
or has icing. For some foods you will be asked to specify the type or variety of the food,
such as the type of bread (100% whole wheat, rye bread, etc.), or the flavor of milk or
yogurt.
It is especially important to complete this column for commercially prepared products and
items that you add to the form. Please provide as complete a description of the item as
possible. Depending on the item, this may include information on:
✓ type (100% whole wheat bread, rye bread, bean burrito)
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
✓
✓
✓
✓
✓
✓
form (fresh, frozen or canned vegetable or fruit)
flavor (strawberry milk, oatmeal cookie, vanilla yogurt)
fat content (low-fat yogurt, reduced-fat sour cream, fat-free salad dressing)
sodium content (low-sodium green beans, reduced-sodium pizza)
sugar content (sweetened, unsweetened, or reduced sugar)
whether whole grain-rich
Column F: Check Box if USDA Food
For food items in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column F.
Column G: Check Box if Prepared from a Recipe
For foods in Column A that are prepared from a recipe—that is, foods that are made by
combining two or more foods or ingredients—place a check mark in Column G. Use these
checkmarks to remind you to complete a Recipe Form or provide a printed recipe.
We have shaded this column for pre-listed foods that do not require recipes. If the column
is not shaded, you may need a recipe, depending on the food. For example, for purchased
pizza that is served as is, a recipe is not needed. For pizza that is a modified version of a
purchased product (for example, you added your own toppings), a recipe is needed.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
Instructions for Completing the
Recipe Forms
Purpose:
To describe the types and amounts of ingredients used in preparing foods
made by combining two or more foods or ingredients.
Location:
A booklet of Recipe Forms (grey) is located behind the “Recipes” tab in the
Menu Survey Folder. If you need more forms than are included in the
booklet, make copies of the form and file the completed extra forms inside
the Recipe Form booklet.
Notes:
•
You may not have to fill out the Recipe Form if a printed copy of the recipe
is available. See the special instructions later in this section (page 14).
•
A recipe is needed for every item that is prepared by combining two or more
foods or ingredients. This includes all sandwiches and foods prepared or cooked
with added butter, margarine, dressings, or other condiments.
•
Some foods may need more than one Recipe Form. For example, for a tuna
salad sandwich, you will need to use two Recipe Forms—one for the tuna salad
mixture and one for the assembled tuna salad sandwich. The same is true for a
brownie or cake with icing. See the sample completed Recipe Forms for an
example of a situation where two Recipe Forms are needed.
•
If the same recipe was prepared more than once during the target week, you
only need to fill out a Recipe Form once and be sure to check the boxes at the top
of the form to indicate which days of the week the recipe was served, unless the
recipe is prepared differently on other days of the week. If variations of a recipe
are used on different days, a separate Recipe Form is needed for each variation.
•
Be sure to look at the sample completed Recipe Forms that are provided.
Looking at these forms as you read the instructions will make it easier to
understand what you need to do when filling out the form.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
How to Complete the Recipe Forms
Recipe/Food Name
Write the complete name of the recipe or food on the line provided in the upper righthand corner of the form. Please be sure that the name is clear enough that we will be
able to match it up with the appropriate item on the Reimbursable Foods Form.
For recipes that are used in other recipe items, mention both recipes in the name. For
example, “Tuna salad for tuna sandwich.”
Meal
Check the meal or meals in which the recipe/food item was offered.
Day
Check the day or days of the target week on which the recipe/food was offered. Check
“all” if the item is offered every day.
Size of One Serving
Write the size of one individual serving, as offered to students. Include both the amount
and unit of measure (Examples: 1/4 cup, 8 fluid ounces, 1 sandwich).
Number of Servings Prepared
Please record the total number of individual servings prepared (recipe yield) in the
space provided. For some items, such as sandwiches, the Recipe Form describes the
ingredients or components of a single serving (Examples: 1 sandwich, 1 Chef’s salad).
Column A: Ingredient Name
List all foods and ingredients used to prepare the recipe/food. Remember to include all
items used in food preparation, including seasonings and salt, as well as oils, butter,
margarine, and other fats used in cooking.
Column B: Amount in Recipe
For each item listed in Column A, write the amount used in Column B. Be sure to include
information on both the amount and the unit of measure (Examples: 2 Tbsp, 6 oz, 5
cups, 7.5 gallons, 35 lbs).
Be sure to provide amount information on the form of the ingredient when it was
measured. For example, was pasta or rice measured cooked or uncooked? Was meat
measured raw or after cooking? Was the cheese sliced, cubed, shredded, or grated?
Column C: Manufacturer/Brand Name and Product Code
If the ingredient or food listed in Column A is a commercially prepared food, list the
manufacturer and/or brand name as well as the product code.
Column D: Ingredient Description
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
For each item listed in Column A, use this column to provide details about the food or
ingredient. Depending on the item, this may include information on:
✓
✓
✓
✓
✓
✓
✓
type (whole wheat flour, brown rice, ground turkey)
form (fresh, frozen or canned vegetables, fruits, or meats)
cooking status (cooked, uncooked, dry, raw)
fat content (part-skim cheese, 1% fat milk, fat-free mayonnaise)
sodium content (low-sodium tomato sauce, reduced-sodium deli turkey)
sugar content (sweetened, unsweetened, or reduced sugar)
whether whole grain-rich
See the sample completed forms for examples of ingredient descriptions.
Column E: Check Box if USDA Food
For ingredients in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column E.
Column F: Check Box if Prepared from a Recipe
For ingredients in Column A that require a recipe, place a check mark in the appropriate
box in Column F. Use these checkmarks to remind you to complete an additional Recipe
Form.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
If You Can Provide a Printed Copy of the Recipe…
Be sure to:
•
Staple or clip a copy of the printed recipe to a blank Recipe Form in the booklet
and indicate on the Recipe Form the meal and days the recipe was used.
•
Mark the recipe, as needed, to show how the recipe was prepared in your school,
and make sure the name of the recipe matches the name used on the
Reimbursable Foods Form.
Make sure the recipe includes:
•
Yield information: size of one serving and number of servings prepared.
•
A complete description of all ingredients, including manufacturer and/or brand and
product code for commercially prepared food products.
•
An indication of any ingredients that are USDA Foods, for example, write “USDA”
beside the ingredient name.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
Instructions for Completing the Self-Serve/
Made-to-Order Bar Forms
Purpose:
To describe the ingredients included on self-serve bars such as salad bars,
theme bars, and condiment bars; made-to-order bars such as deli bars.
Location:
A booklet of Self-Serve/Made-to-Order Bar Forms (lavender) is located
behind the “Self-Serve Bars” tab in the Menu Survey Folder.
Notes:
•
A separate Self-Serve/Made-to-Order Bar Forms must be completed for each type
of self-serve bar or made-to-order bar offered. If the same bar was offered more
than once during the target week, you only need to fill out one Self-Serve/Madeto-Order Bar Forms and indicate the days on which the bar was offered. If the
foods/ingredients offered on the bar differ on other days of the week, a
separate form is needed for each day they are different.
•
Be sure to look at the sample completed Self-Serve/Made-to-Order Bar
Forms that are provided. Looking at these forms as you read the instructions will
make it easier to understand what you need to do when filling out the form.
How to Complete the Self-Serve/Made-to-Order Bar Forms
Name of Bar
Write the complete name of the self-serve/made-to-order bar on the line provided in the
upper right-hand corner of the form. Please be sure that the name is clear enough that
we will be able to match it up with the same item on the Reimbursable Foods Form.
Meal
Check the meal or meals in which the bar was offered during the target week.
Day
Check the day or days of the target week on which the bar was offered. Check “all” if the
bar (with all the same ingredients) is offered every day.
Column A: Food Name
List all foods and ingredients offered on the bar. If you need additional lines, write the
name of the bar and “continued” on a blank Self-Serve/Made-to-Order Bar Form and list
remaining foods/ingredients.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
Column B: Portion Size (if pre-portioned)
For pre-portioned items only, describe the size of one portion. This includes items such
as baked potatoes, tortillas, packaged crackers, boxes of raisins, or packages of
sunflower seeds. It also includes items that might be portioned out by cafeteria servers,
such as pasta on a pasta bar, cold cuts on a deli bar, or meat and cheese items on a
salad bar.
Be sure to include information on both the amount and the unit of measure for preportioned items. See the sample completed Self-Serve/Made-to-Order Bar Forms for
examples.
Column C: Manufacturer/Brand Name and Product
For commercially prepared food products, please record the manufacturer and/or brand
name and a product code in Column C.
Column D: Food Description
For each item listed in Column A, use this column to provide details about the food or
ingredient. Depending on the item, this may include information on:
✓ type (100% whole grain bread, rye bread, graham cracker, cheddar cheese,
deli turkey)
✓ form (fresh, frozen or canned vegetables or fruit)
✓ cooking status (cooked, uncooked, dry, raw)
✓ fat content (low-fat yogurt, reduced-fat sour cream, fat-free salad dressing)
✓ sodium content (low-sodium green beans, reduced-sodium deli turkey)
✓ whether whole grain-rich
See the sample completed forms for examples of ingredient descriptions.
Column E: Check Box if USDA Food
For foods in Column A that are donated USDA Foods, including processed USDA
Foods, place a check mark in the box in Column E.
Column F: Check Box if Prepared from a Recipe
For foods in Column A that require a recipe, place a check mark in the appropriate box
in Column F. Use these checkmarks to remind you to complete a Recipe Form.
Note: Recipes are needed for all items that are made by combining two or more
foods or ingredients.
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
Instructions for Completing the Form for
Non-Program Foods Sold by School Food Service
Purpose:
To describe non-program foods and beverages that are sold only outside of
reimbursable meals and to provide information on the number of each item
sold—either each day of the target week or as a total across the week.
Notes:
•
Non-program foods include foods and beverages that are not offered as part of
reimbursable meals during the target week.
•
Include only non-program foods from venues that are operated or stocked
by your food service department, including foods sold on an a la carte-only basis
in cafeteria serving lines, in vending machines, snack bars, school stores, food
trucks, and food carts.
•
You will use one Form for Non-Program Foods Sold by School Food Service for
the target week. If you are providing information on number of each item sold each
day, you will leave the Weekly Total column blank. If you are providing information
on the number each item sold across the week, you will complete the Weekly Total
column only.
•
You may need to use your daily production records, storeroom inventory, front-ofthe-house stocking records, or ordering and inventory sheets for non-program
foods, if available, to help you fill out this form.
•
Be sure to look at the sample completed Form for Non-Program Foods Sold
by School Food Service that is provided. Looking at this sample as you read
the instructions will make it easier to understand what you need to do when filling
out the form.
How to Complete the Form for Non-Program Foods Sold by
School Food Service
Where Sold
Non-program foods may be sold on cafeteria serving lines or in other venues, such as
vending machines, snack bars, school stores, food trucks, food carts or at another
school or facility off-site. Indicate the venues where the non-program food items listed
on this form are sold, checking all boxes that apply. If the food service department sells
non-program foods in a venue that is not listed, check “Other,” and write in the name of
the venue.
Column A: Food Name
At the start of the target week, use this column to list all non-program items (foods and
beverages) that are sold across all venues operated or stocked by your food service
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
department. Creating a list of items at the start of the week will make the form easier to
fill out.
If an item is available in different flavors but the brand and package sizes are the same,
(for example, different flavors of 12 fl oz Izze Sparkling Juice®), you can list the items
once.
Column B: Portion Size
For each non-program food and beverage item, write the size of one individual serving,
as sold to students. Include both the amount and the unit of measure.
•
For items that are pre-packaged, record the actual package size, weight, or volume
(2.5 oz or 12 fl oz), not “1 package.”
•
For items prepared from recipes, write the size of one individual serving (“1/2 cup”
vanilla pudding) or simply the number of items offered (“1 sandwich,” “2 pieces,”
or “1 each”).
•
If a food or beverage item is sold in more than one portion size, list the item more
than once, on separate lines for each portion size.
A.
B.
Portion Size
(Include Units)
Food Item
Crackers
0.75 oz
Crackers
1.0 oz
Column C: Manufacturer/Brand Name and Product Code
For commercially prepared or pre-packaged items that are not prepared from a recipe,
please record the manufacturer/brand name and a product code (if available) in Column
C. Below are examples of manufacturer/brand names and products codes for some
foods.
A.
C.
Food Item
Manufacturer/Brand Name and Product Code
Pretzels
Snyder’s of Hanover, Item 107641
Corndog
Foster Farms, Code 94124
Cheese breadstick or pizza stick
Bosco’s Pizza Co, Code 2672
Column D: Food Description
For each item listed in Column A, use this column to provide details about the type or
variety of the food. Please provide as complete a description of the item as possible.
Depending on the item, this may include information on:
✓ type: (blueberry muffin, bean burrito or turkey sandwich)
✓ form (fresh, frozen or canned vegetable or fruit)
INSTRUCTIONS FOR THE MENU SURVEY (FULL, OUTLYING AREAS)
✓
✓
✓
✓
flavor (strawberry milk, oatmeal cookie or vanilla yogurt)
fat content (low-fat yogurt, reduced-fat sour cream, or fat-free salad dressing)
sugar content (sweetened, unsweetened, or reduced sugar)
sodium content (low-sodium vegetable juice or reduced-sodium pizza)
If an item is available in different flavors or varieties indicate this in Column D (Food
Description).
Column E: Check Box if Whole Grain-Rich
For food items in Column A that are whole grain-rich, place a check mark in the box in
Column E.
Column F: Check Box if Prepared from a Recipe
If an item was prepared from a recipe, check the box in Column F. Use these
checkmarks to remind you to complete a Recipe Form or provide a printed recipe.
Remember that recipes are needed for all items that are made by combining two or
more foods or ingredients.
Column G: Number of Portions Sold
If you are providing information on number of portions of each item sold each day of the
target week, complete the number of portion columns for each day, and leave the Weekly
Total column blank. If you are providing information on the number of portions sold
across the week, complete only the Weekly Total column (and leave each day’s column
blank).
For all non-program items, enter the total number of portions sold that day, or over the
week if providing number of portions sold across the week. If an item is offered but none
are sold, be sure to enter zero.
Sent Off-Site (if applicable)
If your school sends any non-program foods or beverages to other schools or facilities,
include the number of portions of each item that are sent off-site in the Sent Off-Site
column. Include the total portions of each item that are sent off-site across the week.
Column H: Availability
For each item listed in Column A, use this column to indicate whether the food or
beverage was available for students to purchase during breakfast, during lunch, and/or
outside of meal periods. If the item was available during more than one meal period or at
any time throughout the school day, select all options that apply.
F02.1A. SAMPLE DAILY MEAL COUNTS FORM
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Daily Meal Counts Form
School Name: John Smith Middle____________________
Date: 1/20/25
Instructions:
1.
In the boxes for the Number of Reimbursable NSLP Lunches Served and Number of Reimbursable SBP Breakfasts Served, please
record the number of free, reduced-price, and full-price reimbursable meals served in your school each day of the target week. Do not
include meals for which you do not claim reimbursement, for example, second lunches sold to students on an a la carte basis. If your school
provides free meals to all students, record the number of meals served in the “free” column.
2.
Check the box if the number of reimbursable meals served on a day was much higher or lower than usual, and describe the reason for this
difference in the space provided.
Number of Reimbursable NSLP Lunches Served
Free
ReducedPrice
FullPrice
FOR OFFICE
USE ONLY
Please check if the number of reimbursable lunches
served this day was much higher or lower than usual.
Monday
72
23
30
→ Reason:
_________________________________
Tuesday
85
26
15
→ Reason:
_________________________________
Wednesday
60
12
8
→ Reason: early dismissed _______________________
Thursday
82
23
22
→ Reason:
_________________________________
Friday
78
22
25
→ Reason:
_________________________________
Number of Reimbursable SBP Breakfasts Served
Free
ReducedPrice
FullPrice
FOR OFFICE
USE ONLY
Please check if the number of reimbursable breakfasts
served this day was much higher or lower than usual.
Monday
30
33
12
Tuesday
28
30
12
→ Reason:
→ Reason:
Wednesday
30
32
10
→ Reason:
_________________________________
Thursday
29
32
15
→ Reason:
_________________________________
Friday
38
31
10
→ Reason:
_________________________________
_________________________________
_________________________________
Instructions:
1.
Please record the total value of your non-program food sales by venue, including all student, adult, and other sales in venues operated or stocked
by the food service department. If you do not keep venue-specific records, you may simply enter the total sales across all venues into the last
column (named “Total Across All Venues”). You can either record the sales each day of the target week or enter it as a total across the week in
the last row (named “Weekly Total”).
Total Non-Program Food Sales in Venues Operated or Stocked by the Food Service Department
Serving
Line
(A la
Carte)
Vending
Machine
Snack Bar
School
Store
Food Cart
Food
Trucks
Other:
__________
Total
Across All
Venues
Monday
$248.50
$
$110.00
$
$
$
$
Tuesday
$253.75
$
$95.80
$
$
$
$
Wednesday
$229.42 $
$90.25
$
$
$
$
Thursday
$249.25
$
$101.50
$
$
$
$
Friday
$261.40
$
$97.60
$
$
$
$
Weekly Total
$
$
$
$
$
$
$
F02.1B. SAMPLE REIMBURSABLE FOODS FORM:
BREAKFAST (GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
SAMPLE
Reimbursable Meal Counts
How many reimbursable breakfasts did you plan to serve at your school
this day?
80
How many reimbursable breakfasts did you serve at your school this
day?
75
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
2024-2025 NATIONAL SCHOOL FOODS STUDY
REIMBURSABLE FOODS FORM: BREAKFAST
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
A.
B.
Date: 1/20/25___________________________
C.
Number of Portions
Mon
Day:
Tue
Wed
Thu
D.
E.
F.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
30
19
1
10
0
30
26
2
2
0
0
0
Total
Prepared
Sent
OffSite
Only
sold to
adults
Left Over
for Later
Use
Wasted
Fri
G.
Check Box if
Prepared from
a Recipe
Smith Middle____________________
Check Box if
USDA Food
School Name: John
MILK
White, 1%
8 fl oz.
8 fl oz.
White, 2%
fl oz.
White, whole
fl oz.
White, fat free/skim
Chocolate, fat free/skim
8 fl oz.
20
20
0
Reduced sugar
Chocolate, 1%
fl oz.
Reduced sugar
Chocolate, 2%
fl oz.
Reduced sugar
Lactose free
Other flavor
fl oz.
Specify: Strawberry___
Other flavor
Specify:
__________________
Other flavor
Specify:
__________________
Non-dairy milk alternative,
Specify type:
___________________
8 fl oz.
Fat free/skim
Flavored
20
10
0
10
0
1%
2%
Reduced sugar
Whole
Fat free/skim 1%
Reduced sugar
2%
Whole
Fat free/skim 1%
Reduced sugar
2%
Whole
Fat free/skim 1%
Reduced sugar
2%
Whole
Fat free Light Reduced sugar
Sweetened Unsweetened
Specify flavor(s): ______________
fl oz.
fl oz.
fl oz.
1
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
F.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, complete a RECIPE FORM.)
Fresh
Apple
cup
Applesauce
cup
Sweetened
Fresh
cup
49
0
2
0
1/2 cup
32
2
1
0
1/2 cup
58
2
0
0
Frozen
Unsweetened
Dried
Canned
Light syrup
Frozen
Heavy syrup
Fresh
Canned
Light syrup
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
cup
Fresh
Dried
Heavy syrup
Canned
Light syrup
Extra light syrup Juice
Fresh
Frozen
Heavy syrup
Water
Canned
Light syrup
Extra light syrup Juice Water
cup
Fresh
Peaches
Extra light syrup Juice Water
Orange
Extra light syrup Juice Water
1/2 cup
cup
Canned
Light syrup
Heavy syrup
Fresh
Mandarin oranges
Frozen
Fresh
Sweetened
cup
60
Kiwi
Canned
Light syrup
Heavy syrup
Fresh
Grapes
Dried
Extra light syrup Juice Water
35
Fruit cocktail
Unsweetened
Heavy syrup
Fresh
Blueberries
Extra light syrup Juice Water
50
Banana
Canned
Light syrup
Extra light syrup Juice Water
Apricots
Frozen
Heavy syrup
Dried
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
cup
2
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
F.
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Fresh
Pears, canned
Heavy syrup
Fresh
cup
Raisins
oz.
Strawberries
cup
Canned
Light syrup
Dried
Heavy syrup
Canned
Light syrup
Fresh
Sweetened
Frozen
Unsweetened
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and/or vegetable juice. List fruit drinks (not 100% juice) in the “Other Menu Items” section.)
10
0
40
28
2
4 fl oz.
Apple juice
fl oz.
Orange juice
fl oz.
Fruit juice blend
fl oz.
Extra light syrup Juice Water
Grape juice
Extra light syrup Juice Water
cup
Pineapple
Dried
Calcium added
Reduced sugar
Calcium added
Reduced sugar
Calcium added
Reduced sugar
Calcium added
Reduced sugar
fl oz.
COLD CEREAL (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item. For example, toast w/ cereal).
Apple Jacks
Cheerios, plain
Cheerios, Apple Cinnamon
oz.
Cheerios, Fruity
oz.
Cheerios, Honey Nut
oz.
1 oz.
1 oz.
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
20
20
11
13
0
0
Reduced sugar
9
0
Reduced sugar
Reduced sugar
Reduced sugar
7
0
Cinnamon Toast Crunch
oz.
Reduced sugar
Cocoa Krispies
oz.
Reduced sugar
Cocoa Puffs
oz.
Reduced sugar
Froot Loops
oz.
Reduced sugar
3
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
F.
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Frosted Flakes
oz.
Frosted Mini Wheats
oz.
Reduced sugar
Golden Grahams
oz.
Reduced sugar
Granola
oz.
Regular Low fat
Kix
oz.
Reduced sugar
Lucky Charms
oz.
Reduced sugar
Marshmallow Mateys
oz.
Reduced sugar
Reduced sugar
Raisin Bran
10
1 oz.
8
2
0
0
Reduced sugar
Rice Chex
oz.
Rice Krispies
oz.
Trix
oz.
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
Reduced sugar
HOT CEREALS (Note: If prepared with fat and/or milk, complete a RECIPE FORM)
Cream of Wheat
cup
Grits
cup
Oatmeal
1 cup
40
34
0
Instant
Quick
Whole grain-rich
Regular
Instant
Quick
Regular
Instant
Quick
Regular
0
6
OTHER BREADS AND GRAINS OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item. For example, toast w/
cereal, or biscuit w/ sausage).
Bagel w/ peanut butter
Biscuit
Danish
3 oz.
6
6
0
oz.
0
0
Specify type: 100% whole wheat____________
Reduced fat
Reduced fat Low fat
oz.
Doughnut w/ cereal
2.2 oz.
English muffin, plain
oz.
15
13
2
0
0
Super bakery #6001
Fruit
Cheese
Icing/glaze
No Icing/glaze
Specify type: ___________________
4
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
English muffin, buttered
oz.
Granola/cereal bar
oz.
Muffin w/ cereal
2 oz.
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Margarine
Low fat
Specify type: ___________________
20
19
0
1
0
oz.
Roll, cinnamon
oz.
Toast, plain
oz.
Toast, buttered
oz.
Toaster pastry
oz.
Waffles
Sara lee #4911
Reduced fat
Specify type: blueberry________
Reduced fat
Pancake
Butter
Specify type: ___________________
Specify type: ___________________
Specify type: ___________________
Margarine
Icing
No Icing
G.
Butter
Low fat
Plain Fruit
Chocolate chip
Other:____________
oz.
Plain
Fruit
Chocolate chip
Other:____________
Waffle sticks
F.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
Weight of each stick:_________oz.
ea.
MEATS AND MEAT ALTERNATES OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item.
For example, sausage with biscuit, or yogurt with cereal).
sl
Pork
Eggs
oz.
Scrambled Hard boiled Fried
Cheese
Peanut butter or other
nut/seed butter w/ bagel
oz.
Reduced sodium
Reduced fat
Reduced sugar
Specify type: _________________
Bacon
1 oz.
6
6
0
0
0
Reduced sodium Beef or pork
Sausage
Turkey Vegetarian
Chicken or turkey
oz.
5
Vegetarian
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Specify type: Regular Greek (high protein)
Specify fat: Whole Low fat Fat free Light
Yogurt
F.
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
Specify flavors: _________________
oz.
Bacon
Other:____________
Specify bread type: wheat English muffin_______
Reduced fat
Reduced fat
Weight of each stick:_________oz
Reduced fat
Beef or pork Chicken or turkey
Reduced fat Reduced sodium
Specify toppings: _______________
Specify type:
COMBINATION ITEMS
Eggs Cheese Beans Potato
Breakfast burrito
20
3.5 oz
Egg sandwich
1
sandwich
French toast
oz.
French toast sticks
ea.
Grilled cheese
Pancake on a stick
Other:_______________
oz.
20
0
1
sandwich
2.5 oz.
Pizza
oz.
Quesadilla
oz.
10
9
1
0
0
0
0
Sysco #4629
Cheese
State fair #70601
Sausage
Ham
CONDIMENTS
Self-serve condiments or
fixins’ bar
Butter
Cream cheese
Gravy
1 serving
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
Regular
Light Fat free
Regular
Light Fat free
6
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
1 oz
10
5
0
5
0
Regular Sugar free Reduced sugar
Reduced sodium
2 oz
10
9
1
G.
Margarine
stick
Wasted
Ketchup
Salsa
Syrup w/ pancake on a
Left Over
for Later
Use
Honey
Jelly
Only
sold to
adults
F.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
0
0
Low sodium
Regular Reduced calorie Sugar free
OTHER MENU ITEMS
Grab-n-Go breakfast
1 box
4
4
0
0
0
7
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
F.
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
8
F02.1C. SAMPLE REIMBURSABLE FOODS FORM:
LUNCH (GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
SAMPLE
2024-2025 NATIONAL SCHOOL FOODS STUDY
REIMBURSABLE FOODS FORM: LUNCH
150
How many reimbursable lunches did you serve at your school this day?
125
School Name: John Smith Middle_________________________
B.
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
Date: 1/20/25__________________________
C.
Day:
Mon
Tue
Wed
Thu
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Fri
F.
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
G.
Check Box if
Prepared from a
Recipe
Reimbursable Meal Counts
How many reimbursable lunches did you plan to serve at your school this
day?
A.
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
MILK
White, fat free/skim
8 fl oz.
50
20
5
25
0
White, 1%
8 fl oz.
50
22
2
26
0
White, 2%
fl oz.
White, whole
fl oz.
25
0
Chocolate, fat free/skim
8 fl oz.
Chocolate, 1%
fl oz.
Chocolate, 2%
fl oz.
Lactose free
Other flavor
Specify: strawberry________
8 fl oz.
fl oz.
Other flavor
Specify: ____________________
fl oz.
Other flavor
Specify: ____________________
fl oz.
Non-dairy milk alternative, Specify
type:
___________________
75
75
43
40
7
8
Reduced sugar
Reduced sugar
fl oz.
Reduced sugar
27
0
Fat free/skim 1%
2%
Flavored Reduced sugar
Whole
Fat free/skim 1%
Reduced sugar
2%
Whole
Fat free/skim 1%
Reduced sugar
Fat free/skim 1%
Reduced sugar
2%
Whole
2%
Whole
Fat free Light Reduced sugar
Sweetened Unsweetened
Specify flavor(s): ______________
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, complete a RECIPE FORM.)
Fresh
50
Apple
1/2 cup
Applesauce
1/2 cup
50
0
0
0
50
37
7
4
2
Sweetened
cup
Fresh
cup
Blueberries
cup
cup
50
0
0
0
1/2 cup
Canned
Frozen
Canned
Light syrup
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
cup
Fresh
Frozen
Canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Fresh
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
cup
Fresh
Frozen
Canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Peaches
Frozen
Unsweetened
Dried
Heavy syrup
Fresh
Orange
Extra light syrup Juice Water
cup
Canned
Light syrup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Fresh
Mandarin oranges
Canned
Frozen
Fresh
Sweetened
50
Kiwi
Extra light syrup Juice Water
Fresh
Grapes
Dried
Heavy syrup
Fruit cocktail
Unsweetened
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Banana
Canned
Light syrup
Extra light syrup Juice Water
Fresh
Apricots
Frozen
Heavy syrup
cup
2
G.
Check Box if
Prepared from a
Recipe
A.
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
F.
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Fresh
cup
Fresh
cup
1/4 cup
Raisins
oz.
Strawberries
cup
50
41
4
Frozen
5
0
Fresh
Sweetened
Canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Pineapple
Canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Pears
Frozen
G.
Check Box if
Prepared from a
Recipe
A.
Frozen
Unsweetened
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and/or vegetable juice. Fruit drinks that are not 100% juice should be entered in the “Desserts, Drinks, and Snacks” section.)
Apple juice
fl oz.
Calcium added
Reduced sugar
Grape juice
fl oz.
Calcium added
Reduced sugar
Orange juice
fl oz.
Calcium added
Reduced sugar
Fruit juice blend
fl oz.
Frozen juice cup/bar
fl oz.
Calcium added
Reduced sugar
Specify flavor: ______________
Reduced sugar
fl oz.
VEGETABLES (Note: If beans or peas are being counted as a meat alternate and not a vegetable choice, enter them in the “Other Entrees and Meat/Meat Alternates” section.)
Baked beans
Beans, green
cup
Vegetarian
From: Fresh
Frozen
Canned Low sodium Served raw
Fat added, specify type:
_______________________
cup
3
With meat
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Carrots
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
30
0
0
0
1/2 cup
cup
From: Fresh
Frozen
Canned Low sodium Served raw
Fat added, specify type:
_________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
From: Fresh
Frozen
Canned Low sodium Served raw
Fat added, specify type:
_________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
Cauliflower
cup
Celery, raw
cup
If offered, list dip as separate item(s) or complete a RECIPE FORM
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Corn, kernels
cup
Cucumber, raw
cup
French fries
Lettuce and tomato
(for sandwiches)
cup
Mixed vegetables
1/2 cup
cup
Potatoes, whipped or mashed
cup
If offered, list dip as separate item(s) or complete a RECIPE FORM
Oven-baked
Deep-fried
Reduced sodium
cup
Peas, green
30
30
Refried beans
Manufacturer/Brand Name and
Product Code
(If Applicable)
G.
Food Description
From: Fresh
Frozen
Canned Low sodium Served raw
Fat added, specify type:
________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
30
Broccoli
Sent
OffSite
Check Box if
USDA Food
Number of Portions
Onsite
F.
Check Box if
Prepared from a
Recipe
A.
10
19
2
7
Fresh
Frozen
Canned Low sodium Served raw
Fat added, specify type: margarine______
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
From fresh
From dry Canned
Low sodium
Fat added, specify type:
_________________________
0
18
0
4
1/4 cup
4
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and
Product Code
(If Applicable)
cup
Red peppers
Green peppers
Sweet potatoes
cup
Sweet potato fries or tots
Side salad bar
(non-entrée or small portion)
cup
1
serving
150
110
35
Food Description
From: Fresh
Frozen
Canned Low sodium Served raw
Fat added, specify type:
_________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
From: Fresh
Frozen
Canned Low sodium Served raw
Fat added, specify type:
_________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Oven-baked
Deep-fried
Reduced sodium
cup
Check Box if
USDA Food
Number of Portions
Onsite
0
5
F.
G.
Check Box if
Prepared from a
Recipe
A.
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Specify items:
Side salad
cup
Tater tots or shapes
cup
Tomato, raw
cup
List dressing and any bread/grain items offered with the tossed salad as separate
item(s)
Oven-baked
Deep-fried
Reduced sodium
If offered, list dip as separate item(s) or complete a RECIPE FORM
5
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
SANDWICHES (Note: In Column A, indicate whether any items in this section were offered only with another particular food item. For example, a peanut butter sandwich with a cheese stick, or a grilled cheese sandwich with a yogurt.)
Cheeseburger
1
sandwich
Chicken filet or breast (not
breaded)
1
sandwich
Chicken patty (breaded)
1
sandwich
Fish sandwich
1
sandwich
Grilled cheese
1
sandwich
Ham and cheese
1
sandwich
Hamburger
1
sandwich
Hot dog
1
sandwich
Italian sub
1
sandwich
Peanut butter (or other nut/seed
butter) & jelly w/ yogurt
sandwich
Rib, barbeque
1
sandwich
Sloppy joe
1
sandwich
Turkey
1
sandwich
Tuna salad
1
sandwich
Veggie burger
1
sandwich
1
sandwich
1
sandwich
1
sandwich
1
sandwich
4.8oz
18
5
5
8
5
0
3
0
0
Breaded
7
0
Beef or pork Vegetarian
Chicken or turkey
0
0
Uncrustable 515000655
Reduced sugar
Specify type:________________________
Beef Pork
Chicken or turkey
0
5
6
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
1
sandwich
1
sandwich
ENTRÉE SALADS (Note: List dressing and any bread/grain items offered with an entrée salad as separate item(s). Also, add a note in Column A if a particular bread/grain item is offered only with a particular entrée salad.)
Chef's salad
1 salad
Chicken Caesar salad
1 salad
Taco salad
1 salad
Greek salad w/ chicken
1 salad
6
2
3
1
0
1 salad
1 salad
1 salad
1 salad
1 salad
SELF-SERVE/MADE-TO-ORDER ENTRÉE BARS
Entrée salad bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Potato bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Nacho/taco bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Sandwich/deli bar
1 serving
Pasta/Italian bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
38
25
5
0
8
7
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
OTHER ENTREES AND MEAT/MEAT ALTERNATES (Note: In Column A, indicate whether any items in this section were offered only with another particular food item. For example, a cheese stick with a peanut butter sandwich, a yogurt with a grilled cheese
sandwich, or chicken nuggets with a roll).
Beans or peas
(Specify type)
________________
Burrito
Cheese (string cheese or cubes)
From dry
Canned
Low sodium Fat added, specify type:
_______________
Bean
Beef
Chicken
Cheese
Other:_______________
Reduced fat
Reduced sodium
Reduced fat Reduced sodium
Specify filling(s):
________________________
Oven-baked Deep-fried
Weight of each nugget:________oz.
cup
3.9 oz.
28
20
0
oz.
8
0
Fernandos 90122
Cheese breadstick or pizza stick
oz.
Chicken nuggets (breaded)
ea.
Chicken strips (not breaded)
oz.
Chicken patty (not sandwich)
oz.
Oven-baked
Deep-fried
Breaded
Oven-baked
With skin
Deep-fried
Chicken piece(s)
(Specify
part)_________________
oz.
Corndog
oz.
Egg rolls
Beef or pork
Chicken or turkey
Meatless Beef or pork
Chicken or turkey
Weight of each egg roll:_______oz.
Oven-baked Deep-fried
Breaded
Weight of each nugget/stick:_____oz.
ea.
Fish sticks or nuggets
ea.
Macaroni and cheese
cup
Nachos
oz.
Peanut butter (or other nut/seed
butter)
oz.
Pizza, cheese
5.5 oz.
4.98
Pizza, pepperoni
oz.
Reduced fat
Reduced sugar
Specify type:_______________
Tonys 72671
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French bread)
Tonys 78369
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French bread)
30
30
0
0
0
25
21
4
0
0
8
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Portion
Size
(Include
Units)
Food Item
Pizza, sausage
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
oz.
Pizza, vegetarian
oz.
Pizza pocket
oz.
Stir fry with rice or noodles
cup
Spaghetti with sauce w/ roll
1 cup
Only sold
to adults
Left Over
for Later
Use
Wasted
Food Description
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French bread)
Specify toppings:____________
Reduced fat Reduced sodium
Specify filling:_______________
15
14
0
0
1
oz.
5
Yogurt w/ peanut butter
Manufacturer/Brand Name and
Product Code
(If Applicable)
5
0
G.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French bread)
Taco
Check Box if
USDA Food
Number of Portions
Onsite
F.
Check Box if
Prepared from a
Recipe
A.
0
0
Meat sauce
Marinara sauce
Hard shell Soft tortilla
Bean
Beef
Chicken
Cheese
Specify type: Regular
Greek (high protein)
Specify fat: Whole Low fat
Fat free Light
Specify flavors: _vanilla___________
oz.
sandwich
BREADS AND GRAINS OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with a particular entrée or meat/meat alternate. For example, crackers with Chef’s salad or a roll with chicken nuggets.)
Biscuit
oz.
Reduced fat
Bread, plain
oz.
Specify type:_______________
Bread, buttered
oz.
Specify type:_______________
Margarine
Butter
Breadstick
oz.
Specify type:_______________
Cornbread
oz.
Crackers w/ Greek salad
Croutons
Rice
Roll w/ spaghetti
Pasta
4 oz.
6
2
3
oz.
cup
1 oz.
cup
15
14
0
1
0
Baked
Reduced sodium
Specify type:_whole wheat________
White
1
0
Brown
Wild
Specify type:___white______
9
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
Pretzels
oz.
Tortilla chips
oz.
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and
Product Code
(If Applicable)
Check Box if
USDA Food
Number of Portions
Onsite
F.
Food Description
Soft
Hard
Salted
Unsalted
Lightly salted
Reduced sodium
G.
Check Box if
Prepared from a
Recipe
A.
DESSERTS, DRINKS, AND OTHER SIDES OFFERED AS PART OF A REIMBURSABLE MEAL
Icing/glaze No Icing/glaze
Reduced fat
Reduced fat
Specify type: _______________
Reduced fat Low fat
Specify type: _______________
oz.
Specify type: _______________
fl oz.
Specify type: _______________
Reduced fat Low fat
Specify type: _______________
With fruit
With whipped topping
Reduced fat Reduced sodium Baked
Specify flavor: _______________
Brownie
oz.
Cake
oz.
Cookie
oz.
Fruit crisp or cobbler
Fruit drink (not 100% juice)
Fruit turnover
oz.
Gelatin (Jell-O)
cup
Potato chips
oz.
SALAD DRESSINGS
Caesar dressing
French dressing
Honey mustard dressing
Italian dressing
Regular Light Reduced calorie
Fat free
Regular Light Reduced calorie
Fat free
Regular Light Reduced calorie
Fat free
Regular Light Reduced calorie
Fat free
10
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
Ranch dressing
Greek dressing
Only sold
to adults
2Tbs
6
2
3
1
0
Manufacturer/Brand Name and
Product Code
(If Applicable)
Check Box if
USDA Food
Number of Portions
Onsite
F.
Food Description
Regular Light Reduced calorie
Fat free
G.
Check Box if
Prepared from a
Recipe
A.
Regular Light Reduced calorie
Fat free
Regular Light Reduced calorie
Fat free
CONDIMENTS
Self-serve condiments or fixins’
bar
1
serving
169
125
15
29
0
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
Butter
Cream cheese
Regular Light
Gravy
Regular Fat free
Barbeque sauce
Fat free
Hot sauce
Jalapeno peppers
Honey
Jelly
Ketchup
Margarine
Mayonnaise
Regular Sugar free
Reduced sugar
Reduced sodium
Regular Light Reduced calorie
Fat free
Mustard
Pickles, slices
Ranch dip
Relish
Salsa
Low sodium
Sour cream
Regular Light Fat free
Syrup
Regular Reduced calorie
Sugar free
Tartar sauce
Regular Reduced fat
Regular Light Fat free
11
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
OTHER MENU ITEMS
12
F02.1D SAMPLE RECIPE FORM (GROUP 2A, GROUP 3)
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal:
1
Breakfast
Day:
1
Mon
6
All
2
Smith Middle_______
2
Tue
Lunch
3
3
Wed
Recipe/Food Name: Oatmeal_________________
Other, specify:__________________________________
4
Thu
5
Fri
Size of One Serving (include units): 1
cup
Number of Servings Prepared: 40_____________________
A.
B.
C.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
Rolled oats
20 cups
1% milk
2.5
gallons
D.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
Dry
1
E.
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal:
1
Breakfast
Day:
1
Mon
6
All
2
Smith Middle_______
2
Tue
Lunch
3
3
Wed
Recipe/Food Name: Grab-n-Go
breakfast_____
Other, specify:__________________________________
4
Thu
5
Fri
Size of One Serving (include units): 1
box
Number of Servings Prepared: 1_____________________
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
milk
8 oz
White 1%
orange juice
4 oz
apple
1 medium
fresh
cheerios
2 oz
plain
1
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal:
1
Breakfast
Day:
1
Mon
6
All
2
Smith Middle_______
2
Tue
Lunch
3
3
Wed
Recipe/Food Name: Grilled
Other, specify:___outside
4
Thu
5
Fri
cheese sandwich___
of meal periods___________________________
Size of One Serving (include units): 1
sandwich
Number of Servings Prepared: 1_____________________
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
Bread
2 slices
100% whole wheat
Cheese
2 oz
Cheddar
Margarine
1 tsp
1
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal:
1
Breakfast
Day:
1
Mon
6
All
2
Smith Middle_______
2
Tue
Lunch
3
3
Wed
Recipe/Food Name: tuna
Other, specify:____
4
Thu
5
Fri
salad sandwich______
outside of meal periods _______________
Size of One Serving (include units): 1
sandwich
Number of Servings Prepared: 1_____________________
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
Tuna salad
1 #12
scoop
Bread
2 slices
100% whole wheat
Lettuce
2 small
leaves
Iceberg
1
E.
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Smith Middle_______
Recipe/Food Name: tuna
salad for sandwich and
deli bar_____
Meal:
1
Breakfast
Day:
1
Mon
6
All
2
2
Tue
Lunch
3
3
Wed
Other, specify:__________________________________
4
Thu
5
Fri
Size of One Serving (include units): 1
#12 scoop
Number of Servings Prepared: 24_____________________
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
Tuna
66.5 oz
Chunklight in water
Celery
4 cups
Fresh, diced
Pickle relish
1 cup
sweet
Mayonnaise
3 cups
Regular
Salt
2 Tb
1
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal:
1
Breakfast
Day:
1
Mon
6
All
2
Smith Middle_______
2
Tue
Lunch
3
3
Wed
Recipe/Food Name: Greek
salad with chicken__
Other, specify:__________________________________
4
Thu
5 Fri
Size of One Serving (include units): 1
salad
Number of Servings Prepared: 1_____________________
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
Spinach
1 cup
Fresh, baby
Bell pepper
3 slices
Green, sliced
Cucumber
3 slices
Sliced, w/peel
Onion
2 slices
White, sliced
Olives
1 Tbs
Black, canned
Cheese
1 Tbs
Feta
Chicken
2 oz
Baked, breast, no skin
1
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal:
1
Breakfast
Day:
1
Mon
6
All
2
Smith Middle_______
2
Tue
Lunch
3
3
Wed
Recipe/Food Name: spaghetti
w/meat sauce__
Other, specify:__________________________________
4
Thu
5 Fri
Size of One Serving (include units): 1
Number of Servings Prepared:
A.
B.
C.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
50_____________________
D.
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
Recipe attached
1
cup
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
SAMPLE
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal:
Day:
1
Breakfast
1
Mon
6
All
2
Smith Middle_______
2
Tue
Lunch
3
3
Wed
Recipe/Food Name: fruit
and yogurt parfait__
Other, specify:___outside
4
Thu
5 Fri
of meal periods__________________
Size of One Serving (include units): 8 oz
Number of Servings Prepared: 1_____________________
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
Blueberries
1/8 cup
frozen
Strawberries
1/8 cup
frozen, sliced
Banana
1/4 cup
fresh, sliced
Yogurt
1/2 cup
Lowfat, vanilla
1
F02.1E SAMPLE SELF-SERVE/MADE-TO-ORDER BAR FORM (GROUP 2A, GROUP 3)
SAMPLE
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Self-Serve/Made-to-Order Bar Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal: 1 Breakfast
A.
Food Name
Smith Middle
2
Lunch
B.
Name of Bar:
Day:
1
All
C.
Side Salad bar
2
Mon
3
Tue
4
Wed
D.
Portion Size,
Manufacturer/
If Pre-portioned Brand Name and Product
(Include units)
Code (if applicable)
5
6
Thu
Fri
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Food Description
Lettuce
Romaine
Spinach
Baby
Broccoli
Chopped
Sliced
Tomato
Wedges
Carrot
Baby
Cucumber
Ranch dressing
Low-fat
French dressing
Regular
Italian dressing
Fat-free
1
OMB Control Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Self-Serve/Made-to-Order Bar Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal: 1 Breakfast
A.
Food Name
Smith Middle
2
Lunch
B.
Name of Bar:
Day:
1
All
C.
Portion Size,
Manufacturer/
If Pre-portioned Brand Name and Product
(Include units)
Code (if applicable)
deli bar
2
Mon
3
Tue
4
Wed
D.
5
6
Thu
Fri
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Food Description
bread
2 slices
White
bread
2 slices
100% whole wheat
Italian roll
3 oz
White
mozzarella cheese
1 oz
Part skim, sliced
American cheese
1 oz
Reduced fat, sliced
turkey
2 oz
Oven-baked
ham
2 oz
Reduced fat
White meat, low sodium
tomato
Sliced
lettuce
Iceberg
tuna salad
Chicken strips
#12 scoop
2 oz
Tyson 70351-928
maoyonnaise
1 Tbs
mustard
1 Tbs
peanut butter
2 Tbs
Smooth, regular
jelly
2 Tbs
grape
OMB Control Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Self-Serve/Made-to-Order Bar Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name: John
Meal: 1 Breakfast
A.
Smith Middle
2
Lunch
Day:
1
All
C.
condiment bar
2
Mon
3
Tue
4
Wed
6
Thu
Fri
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Reduced fat
Regular
mustard
Sour cream
Hot sauce
Portion Size,
Manufacturer/
If Pre-portioned Brand Name and Product
(Include units)
Code (if applicable)
D.
5
E.
Food Name
B.
Name of Bar:
Food Description
Ketchup
Ranch dip
Mayonnaise
Salsa
Low sodium
F02.1F. SAMPLE NSLP AFTERSCHOOL SNACK FORM (GROUP 2A, GROUP 3)
SAMPLE
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
2024-2025 NATIONAL SCHOOL FOODS STUDY
NSLP Afterschool Snack Form
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name: __John Smith Middle_________________________________________
1. Please indicate the days that NSLP afterschool snacks were prepared or served during
the target week:
□
□
Monday
Tuesday
Wednesday
Thursday
Friday
NSLP Afterschool Snack Form
Tue
A.
Wed
Thu
Number of Reimbursable Snacks Served Onsite: 48_________
Fri
B.
C.
D.
E.
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Left
Over for
Later
Use
Wasted
Check Box if USDA
Food
Number of Portions
Onsite
G.
Check Box if
Prepared from a
Recipe
Mon
Day:
Milk
fl oz.
Fat free/skim
1%
2%
Whole
2%
Whole
Chocolate
fl oz.
Fat free/skim 1%
Reduced sugar
Lactose free
fl oz.
Fat free/skim
Flavored
2%
Whole
fl oz.
Fat free/skim 1%
Reduced sugar
2%
Whole
fl oz.
Fat free/skim 1%
Reduced sugar
White
Other flavor, Specify:
____________________
Other flavor, Specify:
____________________
1% 2% Whole
Reduced sugar
Fruit
Fresh
Frozen
Heavy syrup
Canned
Light syrup
Apple
cup
Extra light syrup Juice Water
Applesauce, canned
cup
Sweetened
Fresh
Unsweetened
Frozen
Heavy syrup
Banana
cup
Canned
Light syrup
Frozen
Canned
Heavy syrup Light syrup
Extra light syrup Juice Water
cup
Fresh
Frozen
Heavy syrup
Orange
Extra light syrup Juice Water
Fresh
Fruit cocktail
cup
1
Canned
Light syrup
Extra light syrup
Juice Water
NSLP AFTERSCHOOL SNACK FORM
B.
C.
D.
E.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Food Item
Raisins
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Left
Over for
Later
Use
Wasted
USDA Food?
Number of Portions
Onsite
F.
G.
Recipe?
A.
oz.
Juices
Apple juice
Orange juice
Grape juice
fl oz.
6 fl oz.
50
48
2
fl oz.
Calcium added Reduced sugar
Calcium added Reduced sugar
Calcium added Reduced sugar
From: Fresh Frozen
Canned Low sodium
Served raw
Fat added, specify type:
_________________________
Whole grain-rich
Whole grain-rich Reduced fat
Reduced sodium
Thick crust (deep-dish, bagel, French
bread)
Specify toppings:________________
Whole grain-rich
Reduced fat Reduced sodium
Specify type:________________
Vegetables (if offered with a dip, list the dip as a separate item in the condiments section)
Carrots
cup
Celery
cup
Combination Items and Entrées
Peanut butter & jelly
sandwich
Pizza
Sandwich
1
sandwich
oz.
1
sandwich
2
NSLP AFTERSCHOOL SNACK FORM
C.
D.
E.
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Left
Over for
Later
Use
Wasted
G.
Recipe?
B.
USDA Food?
A.
Meat and Meat Alternates
Cheese
oz.
Trail mix
oz.
Reduced fat
Specify type:___________________
Sweetened
Unsweetened
Specify type(s): ______________
Specify type: Regular
Greek (high protein)
Specify fat: Whole Low fat
Fat free Light
Yogurt
oz.
Specify flavor(s): _________________
Breads and Grains
Bagel
Cereal
Cookie
oz.
Whole grain-rich
Specify type: ___________________
oz.
Whole grain-rich
Reduced sugar
Specify type:___________________
oz.
Whole grain-rich
Reduced fat Low fat
Specify type:___________________
50
Crackers
48
Whole grain-rich
Baked Reduced sodium
2
2 oz.
Specify type:___animal
Whole grain-rich Low fat
Granola bar
oz.
Specify type:___________________
3
crackers_
NSLP AFTERSCHOOL SNACK FORM
B.
C.
D.
E.
Food Item
Portion
Size
(Incl.
Units)
Pretzels
Tortilla chips
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Left
Over for
Later
Use
Wasted
Manufacturer/Brand
Name and Product
Code
(If Applicable)
USDA Food?
Number of Portions
Onsite
F.
G.
Recipe?
A.
Food Description
oz.
Whole grain-rich
Soft
Hard
Salted
Unsalted Lightly salted
oz.
Whole grain-rich
Reduced sodium
Specify type:___________________
Whole grain-rich
Whole grain-rich
Whole grain-rich
Desserts and Other Items
Fruit snacks/fruit leather
Fruit drink (less than 100%
juice)
oz.
fl oz.
Low fat Fat free Light
Specify flavor(s): _________________
Pudding
Condiments
Ranch dip
Regular Light Fat free
Cream cheese
Regular Light Fat free
Ketchup
Reduced sodium
4
F02.1G. SAMPLE CACFP AFTERSCHOOL SNACK AND SUPPER
FORM (GROUP 2A, GROUP 3)
SAMPLE
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
2024-2025 NATIONAL SCHOOL FOODS STUDY
CACFP Afterschool Snack and Supper Form
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name: John Smith Middle_________________________________________
1. Please indicate the days that CACFP afterschool snacks and/or suppers were prepared
or served during the target week:
□
□
Monday
Tuesday
Wednesday
Thursday
Friday
CACFP Afterschool Snack and Supper Form
Tue
A.
Wed
Thu
Number of Reimbursable Snacks and/or Suppers Served Onsite: 30_______
Fri
B.
C.
D.
E.
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Check Box if USDA
Food
Number of Portions
Onsite
Food Item
Portion
Size (Incl.
Units)
Total
Prepared/
Available
Sent
OffSite
Reimbursable
Served
Left
Over for
Later
Use
Wasted
G.
Check Box if
Prepared from a
Recipe
Mon
Day:
Milk
White
Chocolate
fl oz.
8 fl oz.
35
30
5
Fat free/skim 1% 2%
Whole
Fat free/skim 1% 2%
Reduced sugar
Whole
fl oz
Fat free/skim 1% 2% Whole
Flavored
Reduced sugar
Other flavor, Specify:
____________________
Whole
fl oz.
Fat free/skim 1% 2%
Reduced sugar
Other flavor, Specify:
____________________
Fat free/skim 1% 2%
Reduced sugar
Whole
fl oz.
Lactose free
Fruit
Fresh
Frozen
Heavy syrup
Apple
Applesauce, canned
35
30
5
Sweetened
Fresh
cup
Canned
Light syrup
Frozen
Canned
Heavy syrup Light syrup
Extra light syrup Juice Water
cup
Fresh
Orange
Extra light syrup Juice Water
Fresh
Fruit cocktail
Unsweetened
Frozen
Heavy syrup
Banana
Extra light syrup Juice Water
cup
1/2 cup
Canned
Light syrup
Frozen
Canned
Heavy syrup Light syrup
Extra light syrup Juice Water
cup
1
CACFP AFTERSCHOOL SNACK AND SUPPER FORM
B.
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
F.
Food Item
Raisins
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Onsite
Left Over
for Later
Use
Wasted
USDA
Food?
Number of Portions
G.
Recipe?
A.
oz.
Juices
Apple juice
fl oz.
Calcium added
Reduced sugar
Orange juice
fl oz.
Calcium added
Reduced sugar
Grape juice
fl oz.
Calcium added
Reduced sugar
Vegetables (if offered with a dip, list the dip as a separate item in the condiments section)
Carrots
cup
Celery, raw
cup
From: Fresh Frozen
Canned Low sodium
Served raw
Fat added, specify type:
_________________________
Oven-baked
cup
Deep-fried
Reduced sodium
French fries
Specify items:
Salad, tossed
Refried beans
cup
1/2 cup
35
30
5
Canned, low sodium
Combination Items and Entrées
Burrito
Cheeseburger
Entrée salad
3.9 oz.
35
30
5
Fernandos 90122
Bean
Chicken
Beef
Cheese
1
sandwich
List dressing as a separate item in the
condiments section
1 salad
2
CACFP AFTERSCHOOL SNACK AND SUPPER FORM
A.
B.
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
F.
USDA
Food?
Recipe?
Number of Portions
G.
Grilled cheese sandwich
1
sandwich
Hamburger
1
sandwich
cup
Whole grain-rich
Whole grain-rich Reduced fat
Specify toppings:
Meat sauce Marinara sauce
Hard shell Soft tortilla
Bean
Beef
Chicken
Cheese
Food Item
Portion
Size
(Incl.
Units)
Macaroni and cheese
Peanut butter & jelly
sandwich
Sent
Off-Site
Reimbursable
Served
Onsite
Left Over
for Later
Use
Wasted
1
sandwich
Pizza
Sandwich
Total
Prepared/
Available
oz.
Whole grain-rich
1
sandwich
Spaghetti with sauce
Specify type:________________
cup
Taco
Meat and Meat Alternates
Cheese
Chicken nuggets
(breaded)
Chicken strips (not
breaded)
Peanut butter
oz.
Reduced fat
Specify type:
ea.
Oven-baked
Deep-fried
Weight of each nugget:
oz
oz.
Reduced fat
oz.
3
CACFP AFTERSCHOOL SNACK AND SUPPER FORM
A.
B.
C.
D.
E.
F.
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Onsite
Left Over
for Later
Use
Wasted
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Specify ingredients:
Trail mix
Recipe?
Food Item
Portion
Size
(Incl.
Units)
USDA
Food?
Number of Portions
G.
oz.
Specify type: Regular
Greek (high protein)
Specify fat: Whole Low fat
Fat free Light
Yogurt
oz.
Specify flavor(s): _________________
Breads and Grains
oz.
Whole grain-rich
Specify type: ___________________
oz.
Whole grain-rich
Reduced sugar
Specify type:___________________
oz.
Whole grain-rich
Reduced fat Low fat
Specify type:___________________
Crackers
oz.
Whole grain-rich
Baked Reduced sodium
Specify type:___________________
Granola bar
oz.
Specify type:___________________
oz.
Whole grain-rich
Soft
Hard
Salted
Unsalted
Lightly salted
oz.
Whole grain-rich
Reduced sodium
Specify type:___________________
Whole grain-rich
Whole grain-rich
Whole grain-rich
Whole grain-rich
Bagel
Cereal
Cookie
Whole grain-rich Low fat
Pretzels
Tortilla chips
4
CACFP AFTERSCHOOL SNACK AND SUPPER FORM
B.
C.
D.
E.
F.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Onsite
Left Over
for Later
Use
Wasted
USDA
Food?
Number of Portions
G.
Recipe?
A.
Desserts and Other Items
Fruit snacks/fruit leather
Fruit drink (less than 100%
juice)
oz.
fl oz.
Low fat Fat free Light
Specify flavor(s): _________________
Regular Light Fat free
Cream cheese
Regular Light Fat free
Ketchup
Reduced sodium
Regular Light
Reduced calorie Fat free
Mayonnaise
Regular Reduced fat
Low-fat Fat free
Mustard
Regular Light Fat free
Reduced calorie
Italian dressing
Regular Light
Reduced calorie
Ranch dressing
Pudding
oz.
Condiments
Ranch dip
Salsa
2 Tb
35
30
5
Fat free
Low sodium, canned
5
F02.10H. FORM FOR NON-PROGRAM FOODS SOLD BY FOOD
SERVICE (GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Form for Non-Program Foods Sold by School Food Service
NOTES:
•
•
•
•
For instructions on completing this form, please refer to Instructions for the Menu Survey.
Use this form to report non-program foods – that is, foods that are sold only outside of reimbursable meals.
Include only non-program foods that are supplied or stocked by your school food service department.
For each food item, record the number of portions sold to students. You can provide this information either each day of the target week or as a total across the week.
School Name:_________John Smith Middle________________________________________
Food Item
B.
Portion
Size
(Incl.
Units)
C.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Snack bar
D.
Vending Machine
E.
Check Box if Whole
Grain-Rich
A.
Serving line lunch
Food Description
Food Cart
Kiosk
School Store
Food Trucks
Other (specify):________________
F.
G.
H.
Check Box if Prepared
from a Recipe
Where Sold: Serving line breakfast
Number of Portions Sold
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Beverages
Milk and Dairy Alternatives
White (unflavored)
Chocolate
Lactose free
Other flavor, Specify:
____________________
Non-dairy milk
alternative, Specify type:
___________________
fl oz.
Fat free/skim
Whole
1%
2%
fl oz.
Fat free/skim 1%
2%
Whole
Reduced sugar
fl oz.
Fat free/skim 1%
Whole Flavored
Reduced sugar
fl oz.
Fat free/skim 1%
2%
Whole
Reduced sugar
Sweetened Unsweetened
fl oz.
Fat free Light
Reduced sugar
Sweetened Unsweetened
Specify flavor(s): ______________
fl oz.
fl oz.
2%
Food Item
100% Juice
Apple juice
B.
C.
Portion
Size
(Incl.
Units)
10 fl oz.
D.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Minute Maid #: 369228088
E.
Check Box if Whole
Grain-Rich
A.
Food Description
Calcium added
Reduced sugar
F.
G.
H.
Check Box if Prepared
from a Recipe
SAMPLE
Number of Portions Sold
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
23
24
23
34
42
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Grape juice
fl oz.
Calcium added
Reduced sugar
Orange juice
fl oz.
Calcium added
Reduced sugar
Fruit juice blend
fl oz.
Calcium added
Reduced sugar
fl oz.
Low sodium Low sugar
Specify flavor(s): ______________
Vegetable juice
fl oz.
fl oz.
fl oz.
No calorie Low calorie
Carbonated
Specify flavor(s): ______________
fl oz.
No calorie Low calorie
Carbonated
Specify flavor(s): ______________
Water Beverages (includes plain or flavored water and water containing juice)
Water, plain
Water, flavored
Water, with juice
Gatorade, G-2
16.9 fl oz.
12 fl oz.
Poland spring
Pepsico GA 58300
45
Assorted flavors
36
4
10
fl oz.
36
0
25
28
25
35
Snacks
Snacks – Fruit
Fresh
Frozen
Heavy syrup
Canned
Light syrup
Apple
cup
Extra light syrup Juice Water
Applesauce, canned
cup
Sweetened
Unsweetened
1
Food Item
B.
C.
Portion
Size
(Incl.
Units)
D.
E.
Check Box if Whole
Grain-Rich
A.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Fresh
Frozen
Heavy syrup
Fruit cocktail, canned
cup
Heavy syrup Light syrup
Extra light syrup Juice
Water
Fruit snacks/fruit leather
oz.
Fruit puree packet
oz.
Frozen
Heavy syrup
cup
Raisins
oz.
Trail mix
oz.
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Specify type(s): ______________
Fresh
Orange
H.
Availability
Canned
oz.
cup
G.
Number of Portions Sold
Light syrup
Extra light syrup Juice Water
Sweetened
Unsweetened
Specify type(s): ______________
Banana
Dried fruit (excluding
raisins)
F.
Check Box if Prepared
from a Recipe
SAMPLE
Canned
Light syrup
Extra light syrup Juice Water
Sweetened
Unsweetened
Specify type(s): ______________
Snacks – Vegetables (if offered with a dip or salad dressing, list as a separate item in the
condiments section)
From: Fresh Frozen Canned
Low sodium Served raw
Fat added, specify type:
_______________________
Carrots
oz.
Celery, raw
oz.
cup
Oven-baked
Deep-fried
Reduced sodium
French fries
cup
Oven-baked
Deep-fried
Reduced sodium
Sweet potato fries or tots
cup
Oven-baked
Deep-fried
Reduced sodium
Tater tots or shapes
2
SAMPLE
C.
Portion
Size
(Incl.
Units)
D.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
E.
F.
G.
H.
Number of Portions Sold
Availability
Check Box if Prepared
from a Recipe
Food Item
B.
Check Box if Whole
Grain-Rich
A.
Food Description
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Snacks – Chips, Crackers, and Bakery Products
Bagel
oz.
Specify type(s): ___________________
Biscuit
oz.
Reduced fat
Breadstick
oz.
Specify type(s):_______________
Cheese-flavored corn
snacks
oz.
Reduced fat
Specify flavor(s): _______________
Baked Reduced sodium
Specify type(s):__cheddar goldfish_
Reduced sugar
Specify type(s):_______________
Pepperidge farm
Crackers
1 oz.
10
0
12
7
9
Cold cereal
oz.
Cornbread
oz.
Croutons
oz.
Granola/cereal bar
oz.
Muffin
oz.
Specify type(s): ___________________
Pita chips
oz.
Specify flavor(s): _______________
Low sodium Unsalted
Buttered Light Plain
Specify flavor(s): ____cheddar__
Low fat
Specify type(s): ___________________
Reduced fat
smartfood
Popcorn
0 .5 oz.
26
22
37
35
14
oz.
Reduced fat Reduced sodium
Baked
Specify flavor(s): _______________
Pretzels
oz.
Soft
Hard
Salted
Unsalted
Lightly salted
Roll, cinnamon
oz.
Icing
Toaster pastry
oz.
Low fat
Potato chips
No icing
3
Food Item
B.
C.
Portion
Size
(Incl.
Units)
Tortilla chips
oz.
Vegetable chips
oz.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
D.
E.
Check Box if Whole
Grain-Rich
A.
Food Description
Reduced sodium
F.
G.
H.
Check Box if Prepared
from a Recipe
SAMPLE
Number of Portions Sold
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Low sodium Low fat
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
oz.
oz.
oz.
Specify type(s): ___________________
Snacks – Desserts
Brownie
oz.
Icing/glaze No Icing/glaze
Reduced fat
Cake
oz.
Reduced fat
Specify type(s): _______________
Pillsbury 0048963
Reduced fat Low fat
Specify type(s): __slice
and bake___
44
36
36
25
25
Cookie
1.5 oz.
Danish
oz.
Reduced fat Low fat
Fruit
Cheese
Doughnut
oz.
Icing/glaze
Frozen juice cup/bar
oz.
100% juice
Specify flavor(s): ______________
Frozen yogurt
oz.
Low fat Fat free
Specify flavor(s): _________________
Fruit turnover
oz.
Reduced fat Low fat
Specify type(s): _______________
Ice cream
oz.
Reduced fat Low fat Fat free
Specify flavor(s): _________________
Pudding
oz.
Low fat Fat free Light
Specify flavor(s): _________________
oz.
No Icing/glaze
4
SAMPLE
C.
D.
E.
F.
G.
H.
Number of Portions Sold
Availability
Check Box if Prepared
from a Recipe
Food Item
B.
Check Box if Whole
Grain-Rich
A.
oz.
oz.
oz.
Portion
Size
(Incl.
Units)
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Snacks – Meats/Meat Alternates
Eggs
oz.
Meat jerky
oz.
Cheese (string cheese
or cubes)
oz.
Scrambled Hard boiled
Fried
Reduced sodium
Specify type(s): _______________
Reduced fat
Reduced sodium
oz.
Reduced fat Reduced sodium
Specify filling(s):
________________________
Chicken nuggets
(breaded)
ea.
Oven-baked Deep-fried
Weight of each nugget:_________oz.
Chicken strips (not
breaded)
oz.
Chicken patty (not
sandwich)
oz.
Cheese breadstick or
pizza stick
Chicken piece(s)
oz.
Oven-baked
Deep-fried
Breaded
With skin
Oven-baked Deep-fried
(Specify part)_________________
Reduced sodium
Sausage
oz.
Beef or pork Chicken or turkey
Smoothie
oz.
Low fat Fat free
Specify flavor(s): _________________
Parfait
oz.
Low fat Fat free
5
Food Item
B.
C.
Portion
Size
(Incl.
Units)
Manufacturer/Brand
Name and Product
Code
(If Applicable)
D.
E.
Check Box if Whole
Grain-Rich
A.
Food Description
Specify type: Regular
Greek (high protein)
Specify fat: Whole Low fat
Yogurt parfait with
fruit
6 oz.
F.
G.
H.
Check Box if Prepared
from a Recipe
SAMPLE
Number of Portions Sold
Availability
Fat free Light
Monday
Tuesday
Wednesday
Thursday
Friday
47
43
34
41
43
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Specify flavor(s): _________________
oz.
oz.
oz.
oz.
oz.
oz.
oz.
Entrées
Burrito
oz.
Specify type: Bean
Beef
Cheese Eggs
Beans
Potato
Other:_______________
oz.
Beef or pork
Chicken or turkey
Corndog
Egg rolls
ea.
Meatless Beef or pork
Chicken or turkey
Weight of each egg roll:__________oz.
French toast
oz.
Reduced fat
ea.
Reduced fat
Weight of each stick:_________oz.
French toast sticks
Nachos
oz.
Reduced fat
oz.
Specify type: ___________________
Pancake
oz.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French
bread)
Reduced fat
Pizza, cheese
6
SAMPLE
C.
D.
E.
F.
G.
H.
Number of Portions Sold
Availability
Check Box if Prepared
from a Recipe
B.
Check Box if Whole
Grain-Rich
A.
oz.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French
bread)
oz.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French
bread)
Pizza, vegetarian
oz.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French
bread)
oz.
Reduced fat Reduced sodium
Specify filling:_______________
Pizza pocket
Taco
oz.
Hard shell Soft tortilla Bean
Beef
Chicken
Cheese
Other:_______________
Waffles
oz.
Plain Fruit Chocolate chip
Other:____________
ea.
Plain Fruit Chocolate chip
Other:____________
Weight of each stick:_________oz.
Food Item
Pizza, pepperoni
Pizza, sausage
Waffle sticks
Sandwich
Entrée salad
Portion
Size
(Incl.
Units)
oz.
1 salad
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Reduced fat Reduced sodium
Specify type(s) of sandwich:
__________________________
Specify type(s) of salad:
__________________________
Monday
Tuesday
7
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Food Item
B.
Portion
Size
(Incl.
Units)
C.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
D.
E.
Check Box if Whole
Grain-Rich
A.
Food Description
F.
G.
H.
Check Box if Prepared
from a Recipe
SAMPLE
Number of Portions Sold
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Condiments (Note: In Column A, indicate wheter any condiments in this section were offered only with a particular entrée or meat/meat alternate)
Barbeque sauce
Butter
Cream cheese
Regular Light Fat free
Jelly
Regular Sugar free
Reduced sugar
Ketchup
Reduced sodium
Hot sauce
Margarine
Mayonnaise
Regular Light Reduced calorie
Fat free
Mustard
Ranch dip
Regular Light Fat free
Salad dressing
Regular Light Reduced calorie
Fat free
Specify type:
______________________
Salsa
Low sodium
Sour cream
Regular Light Fat free
Regular Reduced calorie
Sugar free
Syrup
8
SAMPLE
Portion
Size
(Incl.
Units)
C.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
D.
E.
F.
G.
H.
Number of Portions Sold
Availability
Check Box if Prepared
from a Recipe
Food Item
B.
Check Box if Whole
Grain-Rich
A.
Food Description
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
During During
of meal
breakfast lunch
periods
Other Items
9
F02.01.01.02 MENU SURVEY SCREENER
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
This page has been left blank for double-sided copying.
Note: For the Menu Survey data collection, the burden associated with the instruments in this appendix is included in the burden disclosure statement
for Appendix F02.01.01.
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Menu Survey Screener Questions
Note: The Menu Survey screener questions will be administered prior to the target week to identify which
Menu Survey forms are relevant to a school based on its food service program. Technical assistants
(TAs) will administer the questions over the phone with school nutrition managers (SNMs) and record the
responses in the Electronic Menu Survey (EMS). The EMS will then display the relevant forms on each
school’s task list.
This page has been left blank for double-sided copying.
MENU SURVEY SCREENER QUESTIONS
1.
Does your school participate in the School Breakfast Program (SBP)?
1
0
□
□
Yes
No
[SKIP QUESTIONS 2a-2c FOR FULL OUTLYING AREA SCHOOLS]
2.
Does your school provide reimbursable snacks or suppers for one or more afterschool
programs (either at this school or another location)?
1
0
2a.
0
0
0
Yes
No
□
□
Yes
No
□
□
Yes
No
The next few questions are about non-program foods and beverages that are sold outside of
reimbursable meals by your school’s food service department. Does your school’s food
service department sell any non-program foods or beverages outside of reimbursable
meals?
1
0
4.
□
□
School provides afterschool suppers through the CACFP.
1
3.
No
School provides afterschool snacks through the Child and Adult Care Food Program
(CACFP).
1
2c.
Yes
School provides afterschool snacks through the National School Lunch Program (NSLP).
1
2b.
□
□
□
□
Yes
No [Skip to Q6]
In what locations does your school’s food service department sell non-program foods or
beverages to students outside of reimbursable meals?
MARK ALL THAT APPLY
1
2
3
4
5
6
□
□
□
□
□
□
[If Q1 = Yes] A la carte serving lines at breakfast
A la carte serving lines at lunch
Snack bars
Vending machines
Food carts
Kiosks
1
MENU SURVEY SCREENER QUESTIONS
7
8
9
□
□
□
School stores
Food trucks
Other, Specify: ______________________________
[If Q4 = 3, 4, 5, 6, 7, 8 or 9; else SKIP TO Q5]
4a.
For each of the locations you’ve just reported, are non-program foods and beverages
available to students during breakfast periods, during lunch periods, or outside of meal
periods?
[Display for each Q4 location of 3, 4,
5, 6, 7, 8 or 9]
a. Snack bars
Available during
breakfast
1
b. Vending machines
1
c. Food carts
1
d. Kiosks
1
e. School stores
1
f. Food trucks
1
g. Other, Specify:
______________________________
1
□
□
□
□
□
□
□
Available during
lunch
2
2
2
2
2
2
2
□
□
□
□
□
□
□
Available outside
of meal periods
3
3
3
3
3
3
3
□
□
□
□
□
□
□
[Note: The combination of responses to Q4 and Q4a will determine whether respondents will be asked to
report the availability of each food and beverage item on the Form for Non-Program Foods Sold by Food
Service. If responses to Q4 and Q4a indicate that (1) all locations are available to students during meal
times, or (2) all locations are available to students outside of meal times, then the EMS will not display
Column H on the Form for Non-Program Foods Sold by Food Service (which asks respondents to indicate
the availability of each food and beverage item).]
5.
For non-program foods or beverages sold by your school’s food service department, would
you be able to report how many portions were sold each day? Or as a total across the week?
1
2
0
□
□
□
Yes, each day
Yes, total across the week
No
[SKIP QUESTION 6 FOR FULL OUTLYING AREA SCHOOLS]
6.
Does your school’s food service department prepare foods or meals that are sent or shipped
to another location, school, or facility?
1
0
□
□
Yes
No
2
MENU SURVEY SCREENER QUESTIONS
[If Q6 = Yes]
6a. Which of the following types of foods or meals are sent off-site? (Mark all that apply)
5
□
□
□
□
□
6
□
1
2
3
4
Reimbursable breakfasts
Reimbursable lunches
Afterschool snacks provided through the NSLP [If Q2a = Yes]
Afterschool snacks or suppers provided through the CACFP [If Q2b or Q2c = Yes]
Non-program foods (that is, foods or beverages that are not offered as part of reimbursable
meals) [If Q3 = Yes]
Other
_________________________________
[SKIP QUESTION 7 FOR FULL OUTLYING AREA SCHOOLS]
7.
Is it correct that your school serves students in grades [Y to Z]?
[Y = lowest grade and Z = highest grade, as reported in SFA Director Planning Interview]
1
0
□
□
Yes
No
[If Q7 = No]
7a. What grades does your school serve?
[drop-down lists with values for: pre-kindergarten, kindergarten, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12]
SELECT ONE
Lowest grade: ___________
SELECT ONE
Highest grade: ___________
[Note: The EMS will compute the standard grade group(s) (used in the NSLP/SBP nutrition standards)
that are included in the school, based on the reported grade span of the school:
a. K-5 only
b. 6-8 only
c. 9-12 only
d. K-5 and 6-8
e. K-5 and 9-12
f. 6-8 and 9-12
g. K-5, 6-8, and 9-12
If the school includes grade span combinations d, e, f, or g, the SNM will answer additional questions
when completing the Reimbursable Foods Form in the Electronic Menu Survey. See the instrument
named “Menu Survey Enhancements Administered through the Electronic Menu Survey” for more
details.]
3
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F02.01.01.03. DAILY MEAL COUNTS FORM
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Daily Meal Counts Form
School Name:
Date:
Instructions:
1.
2.
In the boxes for the Number of Reimbursable NSLP Lunches Served and Number of Reimbursable SBP Breakfasts Served, please
record the number of free, reduced-price, and full-price reimbursable meals served in your school each day of the target week. Do not
include meals for which you do not claim reimbursement, for example, second lunches sold to students on an a la carte basis. If your school
provides free meals to all students, record the number of meals served in the “free” column and enter zeroes in the other columns.
Check the box if the number of reimbursable meals served on a day was much higher or lower than usual, and describe the reason for this
difference in the space provided.
Number of Reimbursable NSLP Lunches Served
Free
ReducedPrice
FullPrice
FOR OFFICE
USE ONLY
Please check if the number of reimbursable lunches
served this day was much higher or lower than usual.
Monday
→ Reason:
_________________________________
Tuesday
→ Reason:
_________________________________
Wednesday
→ Reason:
_________________________________
Thursday
→ Reason:
_________________________________
Friday
→ Reason:
_________________________________
Number of Reimbursable SBP Breakfasts Served
Free
ReducedPrice
FullPrice
FOR OFFICE
USE ONLY
Please check if the number of reimbursable breakfasts
served this day was much higher or lower than usual.
Monday
Tuesday
→ Reason:
→ Reason:
Wednesday
→ Reason:
_________________________________
Thursday
→ Reason:
_________________________________
Friday
→ Reason:
_________________________________
_________________________________
_________________________________
Instructions:
1.
Please record the total value of your non-program food sales by venue, including all student, adult, and other sales in venues operated or stocked
by the food service department. If you do not keep venue-specific records, you may simply enter the total sales across all venues into the last
column (named “Total Across All Venues”). You can either record the sales each day of the target week or enter it as a total across the week in
the last row (named “Weekly Total”).
Total Non-Program Food Sales in Venues Operated or Stocked by the Food Service Department
Serving
Line
(A la
Carte)
Snack
Bar
Vending
Machine
Food Cart
School
Store
Kiosk
Food
Trucks
Total
Across
All
Venues
Other:
__________
Monday
$
$
$
$
$
$
$
$
$
Tuesday
$
$
$
$
$
$
$
$
$
Wednesday
$
$
$
$
$
$
$
$
$
Thursday
$
$
$
$
$
$
$
$
$
Friday
$
$
$
$
$
$
$
$
$
Weekly Total
$
$
$
$
$
$
$
$
$
1
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F02.01.01.04. REIMBURSABLE FOODS FORM: BREAKFAST
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
Reimbursable Meal Counts
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
How many reimbursable breakfasts did you plan to serve at your school
this day?
How many reimbursable breakfasts did you serve at your school this
day?
2024-2025 NATIONAL SCHOOL FOODS STUDY
REIMBURSABLE FOODS FORM: BREAKFAST
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
B.
C.
Number of Portions
Mon
Day:
Tue
Wed
Thu
D.
E.
F.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Fri
G.
Check Box if
Prepared from
a Recipe
A.
Date:______________________________
Check Box if
USDA Food
School Name:__________________________________________
MILK
White, fat free/skim
fl oz.
White, 1%
fl oz.
White, 2%
fl oz.
White, whole
fl oz.
Chocolate, fat free/skim
fl oz.
Reduced sugar
Chocolate, 1%
fl oz.
Reduced sugar
Chocolate, 2%
fl oz.
Reduced sugar
Lactose free
Other flavor
Specify:
__________________
Other flavor
Specify:
__________________
Other flavor
Specify:
__________________
fl oz.
Fat free/skim
Flavored
Fat free/skim 1%
Reduced sugar
2%
Whole
Fat free/skim 1%
Reduced sugar
2%
Whole
Non-dairy milk alternative,
Specify type:
___________________
fl oz.
fl oz.
1%
2%
Reduced sugar
Whole
Fat free/skim 1%
2%
Whole
Reduced sugar
Fat free Light Reduced sugar
Sweetened Unsweetened
Specify flavor(s): ______________
fl oz.
fl oz.
1
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
F.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, complete a RECIPE FORM.)
Fresh
Apple
cup
Applesauce, canned
cup
Sweetened
Fresh
Fresh
Blueberries
cup
Fresh
Sweetened
cup
Frozen
Unsweetened
Fresh
Canned
Light syrup
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
cup
Fresh
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice
Fresh
Frozen
Heavy syrup
Water
Canned
Light syrup
Extra light syrup Juice Water
cup
Fresh
Peaches
Extra light syrup Juice Water
Orange
Canned
Light syrup
Frozen
Heavy syrup
cup
cup
Extra light syrup Juice Water
Fresh
Mandarin oranges
Canned
Light syrup
Frozen
Heavy syrup
Kiwi
Extra light syrup Juice Water
Fresh
Grapes
Canned
Light syrup
Frozen
Heavy syrup
Fruit cocktail
Extra light syrup Juice Water
cup
Unsweetened
Dried
Heavy syrup
cup
Banana
Canned
Light syrup
Extra light syrup Juice Water
Apricots
Frozen
Heavy syrup
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
cup
2
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
F.
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Fresh
Pears
Heavy syrup
Fresh
cup
Raisins
oz.
Strawberries
cup
Canned
Light syrup
Extra light syrup Juice Water
cup
Pineapple
Frozen
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
Fresh
Sweetened
Frozen
Unsweetened
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and/or vegetable juice. List fruit drinks (not 100% juice) in the “Other Menu Items” section.)
Apple juice
fl oz.
Grape juice
fl oz.
Orange juice
fl oz.
Fruit juice blend
fl oz.
Calcium added
Reduced sugar
Calcium added
Reduced sugar
Calcium added
Reduced sugar
Calcium added
Reduced sugar
fl oz
fl oz
COLD CEREALS (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item. For example, toast w/ cereal).
Apple Jacks
oz.
Cheerios, plain
oz.
Cheerios, Apple Cinnamon
oz.
Reduced sugar
Cheerios, Fruity
oz.
Reduced sugar
Cheerios, Honey Nut
oz.
Reduced sugar
Cinnamon Toast Crunch
oz.
Reduced sugar
Cocoa Krispies
oz.
Reduced sugar
Cocoa Puffs
oz.
Reduced sugar
Reduced sugar
3
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
F.
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Froot Loops
oz.
Frosted Flakes
oz.
Reduced sugar
Frosted Mini Wheats
oz.
Reduced sugar
Golden Grahams
oz.
Reduced sugar
Granola
oz.
Regular Low fat
Kix
oz.
Reduced sugar
Lucky Charms
oz.
Reduced sugar
Marshmallow Mateys
oz.
Reduced sugar
Raisin Bran
oz.
Reduced sugar
Rice Chex
oz.
Rice Krispies
oz.
Trix
oz.
Reduced sugar
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
Reduced sugar
HOT CEREALS (Note: If prepared with fat and/or milk, complete a RECIPE FORM)
Cream of Wheat
cup
Grits
cup
Oatmeal
cup
Instant
Quick
Whole grain-rich
Regular
Instant
Quick
Regular
Instant
Quick
Regular
OTHER BREADS AND GRAINS OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item. For example, toast w/
cereal, or biscuit w/ sausage).
Bagel
oz.
Biscuit
oz.
Danish
oz.
Doughnut
oz.
English muffin, plain
oz.
Specify type: ___________________
Reduced fat
Reduced fat Low fat
Fruit
Cheese
Icing/glaze
No Icing/glaze
Specify type: ___________________
4
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
English muffin, buttered
oz.
Granola/cereal bar
oz.
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Margarine
Low fat
Muffin
oz.
Pancake
oz.
Roll, cinnamon
oz.
Toast, plain
oz.
Reduced fat
Specify type: ___________________
Reduced fat
Toast, buttered
oz.
Toaster pastry
oz.
Waffles
oz.
Butter
Specify type: ___________________
Specify type: ___________________
Specify type: ___________________
Specify type: ___________________
Margarine
Icing
No Icing
G.
Butter
Low fat
Plain Fruit
Chocolate chip
Other:____________
Plain
Fruit
Chocolate chip
Other:____________
Waffle sticks
F.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
Weight of each stick:_________oz.
ea.
MEATS AND MEAT ALTERNATES OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with another bread/grain item or with a particular meat/meat alternate or combination item.
For example, sausage with biscuit, or yogurt with cereal).
sl
Pork
Eggs
oz.
Scrambled Hard boiled Fried
Cheese
Peanut butter or other
nut/seed butter
oz.
Reduced sodium
Reduced fat
Reduced sugar
Specify type: _________________
Reduced sodium Beef or pork
Bacon
oz.
Sausage
Turkey
Vegetarian
Chicken or turkey Vegetarian
oz.
5
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Specify type: Regular Greek (high protein)
Specify fat: Whole Low fat Fat free Light
Yogurt
F.
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
Specify flavors: _________________
oz.
COMBINATION ITEMS
Eggs Cheese Beans Potato
Breakfast burrito
Other:_______________
oz.
Cheese
Egg sandwich
1
sandwich
French toast
oz.
French toast sticks
ea.
Grilled cheese
1
sandwich
Pancake on a stick
oz.
Pizza
oz.
Quesadilla
oz.
Sausage
Ham
Bacon
Other:____________
Specify bread type: ______________
Reduced fat
Reduced fat
Weight of each stick:_________oz
Reduced fat
Beef or pork Chicken or turkey
Reduced fat Reduced sodium
Specify toppings: _______________
Specify type:
CONDIMENTS
Self-serve condiments or
fixins’ bar
Butter
Cream cheese
Gravy
1 serving
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
Regular
Light Fat free
Regular
Light Fat free
6
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Honey
Jelly
Ketchup
Margarine
Salsa
Syrup
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
F.
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
Regular Sugar free Reduced sugar
Reduced sodium
Low sodium
Regular Reduced calorie Sugar free
OTHER MENU ITEMS
7
REIMBURSABLE FOODS FORM: BREAKFAST
C.
Number of Portions
D.
E.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Onsite
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only
sold to
adults
Left Over
for Later
Use
Wasted
F.
G.
Check Box if
Prepared from
a Recipe
B.
Check Box if
USDA Food
A.
8
F02.01.01.05. REIMBURSABLE FOODS FORM: LUNCH
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Reimbursable Meal Counts
2024-2025 NATIONAL SCHOOL FOODS STUDY
REIMBURSABLE FOODS FORM: LUNCH
How many reimbursable lunches did you plan to serve at your school this
day?
How many reimbursable lunches did you serve at your school this day?
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
A.
B.
C.
Day:
Mon
Tue
Wed
Thu
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
F.
Check Box if
USDA Food
Number of Portions
Onsite
Fri
G.
Check Box if
Prepared from a
Recipe
School Name:___________________________________________ Date:______________________________
MILK
White, fat free/skim
fl oz.
White, 1%
fl oz.
White, 2%
fl oz.
White, whole
fl oz.
Chocolate, fat free/skim
fl oz.
Chocolate, 1%
fl oz.
Chocolate, 2%
fl oz.
Lactose free
fl oz.
Other flavor
Specify: ____________________
fl oz.
Other flavor
Specify: ____________________
fl oz.
Other flavor
Specify: ____________________
fl oz.
Non-dairy milk alternative, Specify
type:
___________________
fl oz.
Reduced sugar
Reduced sugar
Reduced sugar
Fat free/skim 1%
2%
Whole
Flavored Reduced sugar
Fat free/skim 1%
2%
Whole
Reduced sugar
Fat free/skim 1%
2%
Whole
Reduced sugar
Fat free/skim 1%
2%
Whole
Reduced sugar
Fat free Light Reduced sugar
Sweetened Unsweetened
Specify flavor(s): ______________
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, complete a RECIPE FORM.)
Fresh
Apple
cup
Applesauce, canned
cup
Sweetened
cup
Fresh
cup
Blueberries
cup
cup
Fresh
Frozen
Canned
Canned
Light syrup
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
cup
Fresh
Frozen
Canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Fresh
Frozen
Heavy syrup
Canned
Light syrup
Extra light syrup Juice Water
cup
Fresh
Frozen
Canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Peaches
Extra light syrup Juice Water
Orange
Frozen
Unsweetened
Frozen
Heavy syrup
cup
cup
Canned
Light syrup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Fresh
Mandarin oranges
Canned
Frozen
Fresh
Sweetened
Kiwi
Extra light syrup Juice Water
Fresh
Grapes
Dried
Heavy syrup
Fruit cocktail
Unsweetened
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Banana
Canned
Light syrup
Extra light syrup Juice Water
Fresh
Apricots
Frozen
Heavy syrup
cup
2
G.
Check Box if
Prepared from a
Recipe
A.
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
F.
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Fresh
cup
Fresh
cup
Raisins
oz.
Strawberries
cup
Frozen
Canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Pineapple
Canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Pears
Frozen
G.
Check Box if
Prepared from a
Recipe
A.
Fresh
Sweetened
Frozen
Unsweetened
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and/or vegetable juice. Fruit drinks that are not 100% juice should be entered in the “Desserts, Drinks, and Snacks” section.)
Apple juice
fl oz.
Calcium added
Reduced sugar
Grape juice
fl oz.
Calcium added
Reduced sugar
Orange juice
fl oz.
Calcium added
Reduced sugar
Fruit juice blend
fl oz.
Calcium added
Reduced sugar
Frozen juice cup/bar
fl oz.
Specify flavor: ______________
Reduced sugar
fl oz
VEGETABLES (Note: If beans or peas are being counted as a meat alternate and not a vegetable choice, enter them in the “Other Entrees and Meat/Meat Alternates” section.)
Baked beans
Beans, green
Broccoli
Vegetarian
cup
From: Fresh
Frozen Served raw
Canned Low sodium
Fat added, specify type:
_______________________
cup
From: Fresh
Frozen Served raw
Canned Low sodium
Fat added, specify type:
________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
cup
3
With meat
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Carrots
cup
Cauliflower
cup
Celery, raw
cup
cup
Cucumber, raw
cup
French fries
Lettuce and tomato
(for sandwiches)
cup
cup
If offered, list dip as separate item(s) or complete a RECIPE FORM
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
If offered, list dip as separate item(s) or complete a RECIPE FORM
Oven-baked
Deep-fried
Reduced sodium
Fresh
Frozen Served raw
Canned Low sodium
Fat added, specify type: _________________________
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
cup
Peas, green
cup
Potatoes, whipped or mashed
cup
Refried beans
G.
Mixed vegetables
Food Description
From: Fresh
Frozen Served raw
Canned Low sodium
Fat added, specify type:
________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
From: Fresh
Frozen Served raw
Canned Low sodium
Fat added, specify type:
________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
Corn, kernels
Manufacturer/Brand Name and
Product Code
(If Applicable)
Check Box if
USDA Food
Number of Portions
Onsite
F.
Check Box if
Prepared from a
Recipe
A.
From fresh
From dry Canned
Low sodium
Fat added, specify type:
_________________________
cup
4
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
cup
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and
Product Code
(If Applicable)
Red peppers
cup
cup
Sweet potato fries or tots
Side salad bar
(non-entrée or small portion)
cup
1
serving
Food Description
From: Fresh
Frozen Served raw
Canned Low sodium
Fat added, specify type:
________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
From: Fresh
Frozen Served raw
Canned Low sodium
Fat added, specify type:
________________________
If offered, list dip as separate item(s) or
complete a RECIPE FORM
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Oven-baked
Deep-fried
Reduced sodium
Green peppers
Sweet potatoes
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Specify items:
Side salad
cup
Tater tots or shapes
cup
Tomato, raw
cup
List dressing and any bread/grain items offered with the tossed salad as separate
item(s)
Oven-baked
Deep-fried
Reduced sodium
If offered, list dip as separate item(s) or complete a RECIPE FORM
5
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
SANDWICHES (Note: In Column A, indicate whether any items in this section were offered only with another particular food item. For example, a peanut butter sandwich with a cheese stick, or a grilled cheese sandwich with a yogurt.)
Cheeseburger
1
sandwich
Chicken filet or breast (not
breaded)
1
sandwich
Chicken patty (breaded)
1
sandwich
Fish sandwich
1
sandwich
Grilled cheese
1
sandwich
Ham and cheese
1
sandwich
Hamburger
1
sandwich
Hot dog
1
sandwich
Italian sub
1
sandwich
Peanut butter (or other nut/seed
butter) & jelly
1
sandwich
Rib, barbeque
1
sandwich
Sloppy joe
1
sandwich
Turkey
1
sandwich
Tuna salad
1
sandwich
Veggie burger
1
sandwich
1
sandwich
1
sandwich
1
sandwich
1
sandwich
Breaded
Beef or pork
Vegetarian
Chicken or turkey
Reduced sugar
Specify type:________________________
Beef Pork
Chicken or turkey
6
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
1
sandwich
1
sandwich
ENTRÉE SALADS (Note: List dressing and any bread/grain items offered with an entrée salad as separate item(s). Also, add a note in Column A if a particular bread/grain item is offered only with a particular entrée salad.)
Chef's salad
1 salad
Chicken Caesar salad
1 salad
Taco salad
1 salad
1 salad
1 salad
1 salad
1 salad
1 salad
1 salad
SELF-SERVE/MADE-TO-ORDER ENTRÉE BARS
Entrée salad bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Potato bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Nacho/taco bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Sandwich/deli bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Pasta/Italian bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
7
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
OTHER ENTREES AND MEAT/MEAT ALTERNATES (Note: In Column A, indicate whether any items in this section were offered only with another particular food item. For example, a cheese stick with a peanut butter sandwich, a yogurt with a grilled cheese
sandwich, or chicken nuggets with a roll).
Beans or peas
(Specify type)
________________
From dry
Canned
Low sodium Fat added, specify type:
_______________
Bean
Beef
Chicken
Cheese
Other:_______________
Reduced fat
Reduced sodium
Reduced fat Reduced sodium
Specify filling(s):
________________________
Oven-baked Deep-fried
Weight of each nugget:________oz.
cup
Burrito
oz.
Cheese (string cheese or cubes)
oz.
Cheese breadstick or pizza stick
oz.
Chicken nuggets (breaded)
ea.
Chicken strips (not breaded)
oz.
Chicken patty (not sandwich)
oz.
Oven-baked
Deep-fried
Chicken piece(s)
(Specify part)________________
oz.
Breaded
Oven-baked
With skin
Deep-fried
Corndog
oz.
Beef or pork
Chicken or turkey
Meatless Beef or pork
Chicken or turkey
Weight of each egg roll:_______oz.
Oven-baked Deep-fried
Breaded
Weight of each nugget/stick:_____oz.
Egg rolls
ea.
Fish sticks or nuggets
ea.
Macaroni and cheese
cup
Nachos
Peanut butter or other
nut/seed butter
oz.
Pizza, cheese
oz.
Pizza, pepperoni
oz.
oz.
Reduced fat Reduced sugar
Specify type: _________________
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French bread)
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French bread)
8
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Pizza, sausage
Portion
Size
(Include
Units)
oz.
Pizza, vegetarian
oz.
Pizza pocket
oz.
Stir fry with rice or noodles
cup
Spaghetti with sauce
cup
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
G.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French bread)
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel, French bread)
Specify toppings:____________
Reduced fat Reduced sodium
Specify filling:_______________
Meat sauce
Marinara sauce
Hard shell Soft tortilla
Bean
Beef
Chicken
Cheese
Specify type: Regular
Greek (high protein)
Specify fat: Whole Low fat
Taco
Check Box if
USDA Food
Number of Portions
Onsite
F.
Check Box if
Prepared from a
Recipe
A.
oz.
Fat free Light
Yogurt
oz.
Specify flavors: _________________
BREADS AND GRAINS OFFERED SEPARATELY (Note: In Column A, indicate whether any items in this section were offered only with a particular entrée or meat/meat alternate. For example, crackers with Chef’s salad or a roll with chicken nuggets.)
Biscuit
oz.
Reduced fat
Bread, plain
oz.
Specify type:_______________
Bread, buttered
oz.
Specify type:_______________
Margarine
Butter
Breadstick
oz.
Specify type:_______________
Cornbread
oz.
Crackers
oz.
Croutons
oz.
cup
White
Roll
oz.
Specify type:_______________
Pasta
cup
Rice
Baked Reduced sodium
Specify type:_______________
Brown
Wild
9
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
Pretzels
oz.
Tortilla chips
oz.
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Manufacturer/Brand Name and
Product Code
(If Applicable)
Check Box if
USDA Food
Number of Portions
Onsite
F.
Food Description
Soft
Hard
Salted
Unsalted
Lightly salted
Reduced sodium
G.
Check Box if
Prepared from a
Recipe
A.
DESSERTS, DRINKS, AND OTHER SIDES OFFERED AS PART OF A REIMBURSABLE MEAL
Icing/glaze No Icing/glaze
Reduced fat
Reduced fat
Specify type: _______________
Reduced fat Low fat
Specify type: _______________
oz.
Specify type: _______________
fl oz.
Specify type: _______________
Reduced fat Low fat
Specify type: _______________
With fruit
With whipped topping
Reduced fat Reduced sodium Baked
Specify flavor: _______________
Brownie
oz.
Cake
oz.
Cookie
oz.
Fruit crisp or cobbler
Fruit drink (not 100% juice)
Fruit turnover
oz.
Gelatin (Jell-O)
cup
Potato chips
oz.
SALAD DRESSINGS
Caesar dressing
French dressing
Honey mustard dressing
Italian dressing
Regular Light Reduced calorie
Fat free
Regular Light Reduced calorie
Fat free
Regular Light Reduced calorie
Fat free
Regular Light Reduced calorie
Fat free
10
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Ranch dressing
Manufacturer/Brand Name and
Product Code
(If Applicable)
Check Box if
USDA Food
Number of Portions
Onsite
F.
Food Description
Regular Light Reduced calorie
Fat free
G.
Check Box if
Prepared from a
Recipe
A.
Regular Light Reduced calorie
Fat free
Regular Light Reduced calorie
Fat free
CONDIMENTS
Self-serve condiments or fixins’
bar
1
serving
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
Butter
Cream cheese
Regular Light
Gravy
Regular Fat free
Barbeque sauce
Fat free
Hot sauce
Jalapeno peppers
Honey
Jelly
Ketchup
Margarine
Mayonnaise
Regular Sugar free
Reduced sugar
Reduced sodium
Regular Light Reduced calorie
Fat free
Mustard
Pickles, slices
Ranch dip
Relish
Salsa
Low sodium
Sour cream
Regular Light Fat free
Syrup
Regular Reduced calorie
Sugar free
Tartar sauce
Regular Reduced fat
Regular Light Fat free
11
REIMBURSABLE FOODS FORM: LUNCH
B.
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Sent
OffSite
Reimbursable
Served
Sold A La
Carte or to
Adults/Others
Only sold
to adults
Left Over
for Later
Use
Wasted
Check Box if
USDA Food
Number of Portions
Onsite
F.
G.
Check Box if
Prepared from a
Recipe
A.
OTHER MENU ITEMS
12
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F02.01.01.06. RECIPE FORM
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
This page has been left blank for double-sided copying.
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Recipe Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name:
Recipe/Food Name:
Meal:
1
Breakfast
Day:
1
Mon
6
All
2
2
Tue
Lunch
3
3
Wed
Other, specify:__________________________________
4
Thu
5
Fri
Size of One Serving (include units):
Number of Servings Prepared:
A.
B.
C.
D.
Ingredient Name
Amount in
Recipe
(Include
Units)
Manufacturer/
Brand Name and Product
Code
(If Applicable)
1
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Ingredient Description
This page has been left blank for double-sided copying.
F02.01.01.07. SELF-SERVE/MADE-TO-ORDER BAR FORM
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
This page has been left blank for double-sided copying.
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Self-Serve/Made-to-Order Bar Form
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
School Name:
Meal: 1 Breakfast
A.
Food Name
Name of Bar:
2
Lunch
B.
Day:
1
All
C.
2
Mon
3
Tue
4
Wed
D.
Portion Size,
Manufacturer/
If Pre-portioned Brand Name and Product
(Include units)
Code (if applicable)
1
5
6
Thu
Fri
E.
F.
Check
Box if
USDA
Food
Check
Box if
Prepared
from a
Recipe
Food Description
This page has been left blank for double-sided copying.
F02.01.01.08. NSLP AFTERSCHOOL SNACK FORM
(GROUP 2A, GROUP 3)
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
2024-2025 National School Foods Study
NSLP Afterschool Snack Form
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name: __________________________________________________________________
1. Please indicate the days that NSLP afterschool snacks were prepared or served during
the target week:
□
□
□
□
□
Monday
Tuesday
Wednesday
Thursday
Friday
This page has been left blank for double-sided copying.
NSLP Afterschool Snack Form
Tue
A.
Wed
Thu
Fri
B.
Number of Reimbursable Snacks Served Onsite: _________
C.
D.
E.
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Left
Over for
Later
Use
Wasted
Check Box if USDA
Food
Number of Portions
Onsite
G.
Check Box if
Prepared from a
Recipe
Mon
Day:
Milk
White
fl oz.
Fat free/skim
1%
2%
Whole
Whole
fl oz.
Fat free/skim 1%
Reduced sugar
2%
Chocolate
Lactose free
fl oz.
Fat free/skim 1%
2%
Whole Flavored Reduced sugar
2%
Whole
fl oz.
Fat free/skim 1%
Reduced sugar
2%
Whole
fl oz.
Fat free/skim 1%
Reduced sugar
Other flavor, Specify:
____________________
Other flavor, Specify:
____________________
Fruit
Fresh
Frozen
Heavy syrup
Canned
Light syrup
Apple
cup
Extra light syrup Juice Water
Applesauce, canned
cup
Sweetened
Fresh
Unsweetened
Frozen
Heavy syrup
Banana
Fresh
Frozen
Frozen
Heavy syrup
cup
Raisins
oz.
Light syrup
Canned
Heavy syrup Light syrup
Extra light syrup Juice Water
cup
Orange
Canned
Extra light syrup Juice Water
cup
Fresh
Fruit cocktail
Canned
Light syrup
Extra light syrup
Juice Water
1
NSLP AFTERSCHOOL SNACK FORM
B.
C.
D.
E.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Left
Over for
Later
Use
Wasted
USDA Food?
Number of Portions
Onsite
F.
G.
Recipe?
A.
Juices
Apple juice
fl oz.
Calcium added Reduced sugar
Orange juice
fl oz.
Calcium added Reduced sugar
Grape juice
fl oz.
Calcium added Reduced sugar
Whole grain-rich
Whole grain-rich Reduced fat
Reduced sodium
Thick crust (deep-dish, bagel, French
bread)
Specify toppings:________________
Whole grain-rich
Reduced fat Reduced sodium
Specify type: ________________
Vegetables (if offered with a dip, list the dip as a separate item in the condiments section)
From: Fresh Frozen
Canned Low sodium
Carrots
cup
Celery, raw
cup
Served raw
Fat added, specify type:
_________________________
Combination Items and Entrées
Peanut butter & jelly
sandwich
Pizza
Sandwich
1
sandwich
oz.
1
sandwich
2
NSLP AFTERSCHOOL SNACK FORM
B.
C.
D.
E.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Food Item
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Left
Over for
Later
Use
Wasted
USDA Food?
Number of Portions
Onsite
F.
G.
Recipe?
A.
Meat and Meat Alternates
Cheese
oz.
Trail mix
oz.
Reduced fat
Specify type:___________________
Sweetened
Unsweetened
Specify type(s): ______________
Specify type: Regular
Greek (high protein)
Specify fat: Whole Low fat
Fat free Light
Yogurt
oz.
Specify flavor(s): _________________
Breads and Grains
oz.
Whole grain-rich
Specify type: ___________________
oz.
Whole grain-rich
Reduced sugar
Specify type:___________________
oz.
Whole grain-rich
Reduced fat Low fat
Specify type:___________________
Crackers
oz.
Whole grain-rich
Baked Reduced sodium
Specify type:___________________
Granola bar
oz.
Specify type:___________________
oz.
Whole grain-rich
Soft
Hard
Salted
Unsalted Lightly salted
Bagel
Cereal
Cookie
Whole grain-rich Low fat
Pretzels
3
NSLP AFTERSCHOOL SNACK FORM
A.
B.
C.
D.
E.
Tortilla chips
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Left
Over for
Later
Use
Wasted
oz.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Recipe?
Food Item
Portion
Size
(Incl.
Units)
G.
USDA Food?
Number of Portions
Onsite
F.
Whole grain-rich
Reduced sodium
Specify type:___________________
Whole grain-rich
Whole grain-rich
Whole grain-rich
Food Description
Desserts and Other Items
Fruit snacks/fruit leather
Fruit drink (less than 100%
juice)
oz.
fl oz.
Low fat Fat free Light
Specify flavor(s): _________________
Pudding
Condiments
Ranch dip
Regular Light Fat free
Cream cheese
Regular Light Fat free
Ketchup
Reduced sodium
4
This page has been left blank for double-sided copying.
F02.01.01.09. CACFP AFTERSCHOOL SNACK AND SUPPER FORM
(GROUP 2A, GROUP 3)
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
2024-2025 National School Foods Study
CACFP Afterschool Snack and Supper Form
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name: __________________________________________________________________
1. Please indicate the days that CACFP afterschool snacks and/or suppers were prepared
or served during the target week:
□
□
□
□
□
Monday
Tuesday
Wednesday
Thursday
Friday
This page has been left blank for double-sided copying.
CACFP Afterschool Snack and Supper Form
A.
Wed
Thu
Fri
B.
Number of Reimbursable Snacks and/or Suppers Served Onsite: _________
C.
D.
E.
F.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Number of Portions
Onsite
Food Item
Portion
Size (Incl.
Units)
Total
Prepared/
Available
Sent
OffSite
Reimbursable
Served
Left
Over for
Later
Use
Wasted
G.
Check Box if
Prepared from a
Recipe
Tue
Check Box if USDA
Food
Mon
Day:
Milk
White
fl oz.
Fat free/skim 1% 2% Whole
Chocolate
fl oz.
Fat free/skim 1% 2% Whole
Reduced sugar
fl oz.
Fat free/skim 1% 2% Whole
Flavored
Reduced sugar
Other flavor, Specify:
____________________
fl oz.
Fat free/skim 1% 2% Whole
Reduced sugar
Other flavor, Specify:
____________________
fl oz.
Fat free/skim 1% 2% Whole
Reduced sugar
Lactose free
Fruit
Fresh
Frozen
Heavy syrup
Canned
Light syrup
Apple
cup
Extra light syrup Juice Water
Applesauce, canned
cup
Sweetened
Fresh
Unsweetened
Frozen
Heavy syrup
Banana
cup
Canned
Light syrup
Frozen
Canned
Heavy syrup Light syrup
Extra light syrup Juice
Water
cup
Fresh
Frozen
Heavy syrup
Orange
Extra light syrup Juice Water
Fresh
Fruit cocktail
Canned
Light syrup
Extra light syrup Juice Water
cup
1
CACFP AFTERSCHOOL SNACK AND SUPPER FORM
B.
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
F.
Food Item
Raisins
Portion
Size
(Incl.
Units)
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Onsite
Left Over
for Later
Use
Wasted
USDA
Food?
Number of Portions
G.
Recipe?
A.
oz.
Juices
Apple juice
fl oz.
Calcium added Reduced sugar
Orange juice
fl oz.
Calcium added Reduced sugar
Grape juice
fl oz.
Calcium added Reduced sugar
From: Fresh Frozen
Canned Low sodium
Served raw
Fat added, specify type:
_________________________
Vegetables (if offered with a dip, list the dip as a separate item in the condiments section)
Carrots
cup
Celery, raw
cup
Oven-baked
cup
Deep-fried
Reduced sodium
French fries
Specify items:
Salad, tossed
cup
Combination Items and Entrées
Burrito
Cheeseburger
Entrée salad
Bean
Chicken
oz.
Beef
Cheese
1
sandwich
List dressing as a separate item in
the condiments section
1 salad
Grilled cheese sandwich
1
sandwich
Hamburger
1
sandwich
2
CACFP AFTERSCHOOL SNACK AND SUPPER FORM
A.
B.
C.
D.
E.
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
F.
Macaroni and cheese
Peanut butter & jelly
sandwich
Sent
Off-Site
Reimbursable
Served
Onsite
Left Over
for Later
Use
Wasted
Whole grain-rich
Whole grain-rich Reduced fat
Specify toppings:
Meat sauce Marinara sauce
Hard shell Soft tortilla
Bean
Beef
Chicken
Cheese
cup
1
sandwich
Pizza
Sandwich
Total
Prepared/
Available
Recipe?
Food Item
Portion
Size
(Incl.
Units)
USDA
Food?
Number of Portions
G.
oz.
Whole grain-rich
1
sandwich
Spaghetti with sauce
Specify type:________________
cup
Taco
Meat and Meat Alternates
Cheese
Chicken nuggets
(breaded)
Chicken strips (not
breaded)
oz.
Reduced fat
Specify type:
ea.
Oven-baked
Deep-fried
Weight of each nugget:
oz
oz.
Peanut butter
oz.
Trail mix
oz.
Reduced fat
Specify ingredients:
3
CACFP AFTERSCHOOL SNACK AND SUPPER FORM
A.
B.
C.
D.
E.
F.
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Onsite
Left Over
for Later
Use
Wasted
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Specify type: Regular
Greek (high protein)
Specify fat: Whole Low fat
Fat free Light
Yogurt
Recipe?
Food Item
Portion
Size
(Incl.
Units)
USDA
Food?
Number of Portions
G.
Specify flavor(s):
_________________
oz.
Breads and Grains
oz.
Whole grain-rich
Specify type: ___________________
oz.
Whole grain-rich
Reduced sugar
Specify type:___________________
oz.
Whole grain-rich
Reduced fat Low fat
Specify type:___________________
Crackers
oz.
Whole grain-rich
Baked Reduced sodium
Specify type:___________________
Granola bar
oz.
Specify type:___________________
oz.
Whole grain-rich
Soft
Hard
Salted
Unsalted
Lightly salted
oz.
Whole grain-rich
Reduced sodium
Specify type:___________________
Whole grain-rich
Whole grain-rich
Bagel
Cereal
Cookie
Whole grain-rich Low fat
Pretzels
Tortilla chips
Desserts and Other Items
Fruit snacks/fruit leather
Fruit drink (less than 100%
juice)
oz.
fl oz.
4
CACFP AFTERSCHOOL SNACK AND SUPPER FORM
A.
B.
C.
D.
E.
F.
Pudding
Total
Prepared/
Available
Sent
Off-Site
Reimbursable
Served
Onsite
Left Over
for Later
Use
Wasted
Manufacturer/Brand
Name and Product Code
(If Applicable)
Food Description
Low fat Fat free Light
Specify flavor(s):
_________________
oz.
Recipe?
Food Item
Portion
Size
(Incl.
Units)
USDA
Food?
Number of Portions
G.
Condiments
Ranch dip
Regular Light Fat free
Cream cheese
Regular Light Fat free
Ketchup
Reduced sodium
Mayonnaise
Regular Light
Reduced calorie Fat free
Regular Reduced fat
Low-fat Fat free
Mustard
Regular Light Fat free
Reduced calorie
Italian dressing
Regular Light
Reduced calorie
Ranch dressing
5
Fat free
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F02.01.01.10. FORM FOR NON-PROGRAM FOODS SOLD BY FOOD SERVICE
(GROUP 2A, GROUP 3, FULL OUTLYING AREAS)
1
OMB Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Form for Non-Program Foods Sold by School Food Service
NOTES:
•
•
•
•
For instructions on completing this form, please refer to Instructions for the Menu Survey.
Use this form to report non-program foods – that is, foods that are sold only outside of reimbursable meals.
Include only non-program foods that are supplied or stocked by your school food service department.
For each food item, record the number of portions sold to students. You can provide this information either each day of the target week or as a total across the week.
School Name:__________________________________________________
Food Item
B.
Portion
Size
(Incl.
Units)
C.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Snack bar
D.
Vending Machine
E.
Check Box if Whole
Grain-Rich
A.
Serving line lunch
Food Description
Food Cart
Kiosk
School Store
Food Trucks
Other (specify):__________________
F.
G.
H.
Check Box if Prepared
from a Recipe
Where Sold: Serving line breakfast
Number of Portions Sold
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
of meal
periods
During
breakfast
During
lunch
Beverages
Milk and Dairy Alternatives
fl oz.
Fat free/skim
Whole
1%
White (unflavored)
Chocolate
fl oz.
Fat free/skim
Whole
1%
2%
Reduced sugar
fl oz.
Fat free/skim 1%
Whole Flavored
Reduced sugar
fl oz.
Fat free/skim 1%
2%
Whole
Reduced sugar
Sweetened Unsweetened
fl oz.
Fat free Light
Reduced sugar
Sweetened Unsweetened
Specify flavor(s): ______________
fl oz.
fl oz.
fl oz.
Lactose free
Other flavor, Specify:
____________________
Non-dairy milk
alternative, Specify type:
___________________
2%
2%
1
Apple juice
C.
Portion
Size
(Incl.
Units)
fl oz.
D.
E.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
G.
H.
Number of Portions Sold
Availability
During
lunch
Reduced sugar
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
of meal
periods
During
breakfast
Food Description
Calcium added
F.
Check Box if Prepared
from a Recipe
Food Item
100% Juice
B.
Check Box if Whole
Grain-Rich
A.
Grape juice
fl oz.
Calcium added
Reduced sugar
Orange juice
fl oz.
Calcium added
Reduced sugar
Fruit juice blend
fl oz.
Calcium added
Reduced sugar
fl oz.
Low sodium Low sugar
Specify flavor(s): ______________
Vegetable juice
fl oz.
fl oz.
fl oz.
No calorie Low calorie
Carbonated
Specify flavor(s): ______________
fl oz.
No calorie Low calorie
Carbonated
Specify flavor(s): ______________
Water Beverages (includes plain or flavored water and water containing juice)
Water, plain
Water, flavored
Water, with juice
fl oz.
fl oz.
fl oz.
Snacks
Snacks – Fruit
Fresh
Frozen
Heavy syrup
Canned
Light syrup
Apple
cup
Extra light syrup Juice Water
Applesauce, canned
cup
Sweetened
Fresh
Frozen
Heavy syrup
Banana
cup
Unsweetened
Canned
Light syrup
Extra light syrup Juice Water
2
C.
Portion
Size
(Incl.
Units)
D.
E.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
oz.
Sweetened
Unsweetened
Specify type(s): ______________
Fruit cocktail, canned
cup
Heavy syrup Light syrup
Extra light syrup Juice
Water
Fruit snacks/fruit leather
oz.
Fruit puree packet
oz.
Dried fruit (excluding
raisins)
Frozen
Heavy syrup
cup
Raisins
oz.
Trail mix
oz.
G.
H.
Number of Portions Sold
Availability
During
lunch
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
of meal
periods
During
breakfast
Monday
Specify type(s): ______________
Fresh
Orange
F.
Check Box if Prepared
from a Recipe
Food Item
B.
Check Box if Whole
Grain-Rich
A.
Canned
Light syrup
Extra light syrup Juice Water
Sweetened
Unsweetened
Specify type(s): ______________
Snacks – Vegetables (if offered with a dip or salad dressing, list as a separate item in the
condiments section)
From: Fresh Frozen Canned
Low sodium Served raw
Fat added, specify type:
_______________________
Carrots
oz.
Celery, raw
oz.
cup
Oven-baked
Deep-fried
Reduced sodium
French fries
cup
Oven-baked
Deep-fried
Reduced sodium
Sweet potato fries or tots
cup
Oven-baked
Deep-fried
Reduced sodium
Tater tots or shapes
3
C.
D.
E.
F.
G.
H.
Number of Portions Sold
Availability
Check Box if Prepared
from a Recipe
B.
Check Box if Whole
Grain-Rich
A.
Bagel
oz.
Specify type(s):
___________________
Biscuit
oz.
Reduced fat
Portion Manufacturer/Brand
Size
Name and Product
(Incl.
Code
Food Item
Units)
(If Applicable)
Snacks – Chips, Crackers, and Bakery Products
Food Description
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
During
breakfast
During
lunch
Outside
of meal
periods
Breadstick
oz.
Specify type(s):_______________
Cheese-flavored corn
snacks
oz.
Reduced fat
Specify flavor(s): _______________
Crackers
oz.
Baked Reduced sodium
Specify type(s):_______________
Cold cereal
oz.
Reduced sugar
Specify type(s):_______________
Cornbread
oz.
Croutons
oz.
Low fat
Granola/cereal bar
oz.
Specify type(s):
___________________
Reduced fat
oz.
Specify type(s):
___________________
Muffin
Pita chips
oz.
Specify flavor(s): _______________
oz.
Low sodium Unsalted
Buttered Light Plain
Specify flavor(s): _______________
oz.
Reduced fat Reduced sodium
Baked
Specify flavor(s): _______________
Pretzels
oz.
Soft
Hard
Salted
Unsalted
Lightly salted
Roll, cinnamon
oz.
Icing
oz.
Low fat
Popcorn
Potato chips
Toaster pastry
No icing
4
C.
Portion
Size
(Incl.
Units)
oz.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
D.
E.
Food Description
Reduced sodium
F.
G.
H.
Check Box if Prepared
from a Recipe
Food Item
Tortilla chips
B.
Check Box if Whole
Grain-Rich
A.
Number of Portions Sold
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
of meal
periods
During
breakfast
During
lunch
Low sodium Low fat
Vegetable chips
oz.
oz.
oz.
oz.
Specify type(s):
___________________
Snacks – Desserts
Brownie
oz.
Icing/glaze No Icing/glaze
Reduced fat
Cake
oz.
Reduced fat
Specify type(s): _______________
Cookie
oz.
Reduced fat Low fat
Specify type(s): _______________
Danish
oz.
Reduced fat Low fat
Fruit
Cheese
Doughnut
oz.
Icing/glaze
Frozen juice cup/bar
oz.
100% juice
Specify flavor(s): ______________
Frozen yogurt
oz.
Low fat Fat free
Specify flavor(s): _________________
Fruit turnover
oz.
Reduced fat Low fat
Specify type(s): _______________
Ice cream
oz.
Reduced fat Low fat Fat free
Specify flavor(s): _________________
Pudding
oz.
Low fat Fat free Light
Specify flavor(s): _________________
No Icing/glaze
oz.
oz.
oz.
5
C.
Portion Manufacturer/Brand
Size
Name and Product
(Incl.
Code
Food Item
Units)
(If Applicable)
Snacks – Meats/Meat Alternates
Eggs
oz.
Meat jerky
oz.
Cheese (string cheese or
cubes)
oz.
D.
E.
Food Description
Scrambled Hard boiled
Fried
Reduced sodium
Specify type(s): _______________
Reduced fat
Reduced sodium
F.
G.
H.
Check Box if Prepared
from a Recipe
B.
Check Box if Whole
Grain-Rich
A.
Number of Portions Sold
Availability
During
lunch
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
Outside
of meal
periods
During
breakfast
Monday
oz.
Reduced fat Reduced sodium
Specify filling(s):
________________________
Chicken nuggets
(breaded)
ea.
Oven-baked Deep-fried
Weight of each nugget:_________oz.
Chicken strips (not
breaded)
oz.
Chicken patty (not
sandwich)
oz.
Cheese breadstick or
pizza stick
Chicken piece(s)
oz.
Oven-baked
Deep-fried
Breaded
With skin
Oven-baked Deep-fried
(Specify part)_________________
Reduced sodium
Sausage
oz.
Beef or pork Chicken or turkey
Smoothie
oz.
Low fat Fat free
Specify flavor(s): _________________
Parfait
oz.
Low fat Fat free
Specify type: Regular
Greek (high protein)
Specify fat: Whole Low fat
Fat free Light
Yogurt
oz.
Specify flavor(s): _________________
oz.
oz.
6
C.
D.
E.
F.
G.
H.
Number of Portions Sold
Availability
Check Box if Prepared
from a Recipe
B.
Check Box if Whole
Grain-Rich
A.
oz.
oz.
oz.
Specify type: Bean
Beef
Cheese Eggs
Beans
Potato
Other:_______________
oz.
Beef or pork
Chicken or turkey
Egg rolls
ea.
Meatless Beef or pork
Chicken or turkey
Weight of each egg roll:__________oz.
French toast
oz.
Reduced fat
French toast sticks
ea.
Reduced fat
Weight of each stick:_________oz.
Nachos
oz.
Reduced fat
Food Item
Portion
Size
(Incl.
Units)
Manufacturer/Brand
Name and Product
Code
(If Applicable)
Food Description
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
During
breakfast
During
lunch
Outside
of meal
periods
Entrées
Burrito
Corndog
Reduced fat
oz.
Specify type: ___________________
oz.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel,
French bread)
oz.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel,
French bread)
oz.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel,
French bread)
Pizza, vegetarian
oz.
Reduced fat Reduced sodium
Thick crust (deep-dish, bagel,
French bread)
oz.
Reduced fat Reduced sodium
Specify filling:_______________
Pizza pocket
Pancake
Pizza, cheese
Pizza, pepperoni
Pizza, sausage
7
C.
Portion
Size
(Incl.
Units)
Manufacturer/Brand
Name and Product
Code
(If Applicable)
D.
E.
F.
G.
H.
Number of Portions Sold
Availability
Check Box if Prepared
from a Recipe
Food Item
B.
Check Box if Whole
Grain-Rich
A.
Food Description
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
During
breakfast
During
lunch
Outside
of meal
periods
Taco
oz.
Hard shell Soft tortilla Bean
Beef
Chicken
Cheese
Other:_______________
Waffles
oz.
Plain Fruit Chocolate chip
Other:____________
ea.
Plain Fruit Chocolate chip
Other:____________
Weight of each stick:_________oz.
Waffle sticks
Sandwich
Entrée salad
oz.
1 salad
Reduced fat Reduced sodium
Specify type(s) of sandwich:
__________________________
Specify type(s) of salad:
__________________________
Condiments (Note: In Column A, indicate wheter any condiments in this section were offered only with a particular entrée or meat/meat alternate)
Barbeque sauce
Butter
Cream cheese
Regular Light Fat free
Hot sauce
Regular Sugar free
Reduced sugar
Jelly
Ketchup
Reduced sodium
Margarine
Mayonnaise
Regular Light Reduced calorie
Fat free
Mustard
8
Portion
Size
(Incl.
Units)
C.
Manufacturer/Brand
Name and Product
Code
(If Applicable)
D.
E.
Food Description
F.
G.
H.
Check Box if Prepared
from a Recipe
Food Item
B.
Check Box if Whole
Grain-Rich
A.
Number of Portions Sold
Availability
Monday
Tuesday
Wednesday
Thursday
Friday
Weekly
Total
Sent
Off-Site
During
breakfast
During
lunch
Outside
of meal
periods
Ranch dip
Regular Light Fat free
Salad dressing
Regular Light Reduced calorie
Fat free
Specify type:
______________________
Salsa
Low sodium
Sour cream
Regular Light Fat free
Regular Reduced calorie
Sugar free
Syrup
Other Items
9
F02.01.01.11. MENU SURVEY ENHANCEMENTS ADMINISTERED THROUGH
THE ELECTRONIC MENU SURVEY (EMS)
(GROUP 2A, GROUP 3)
OMB Control Number: 0584-xxxx
Expiration Date: xx/xx/20xx
Questions Related to Offering Different Foods
and/or Portion Sizes to Students in
Different Grade Groups (Group 2a and Group 3)
Note: If the school includes students from more than one of the standard grade groups used in the
NSLP/SBP nutrition standards (computed based on responses to Screener Q7 and Q7a), the Electronic
Menu Survey (EMS) will include additional questions on the Reimbursable Foods Form (for lunch and
breakfast) that ask about offering different foods and/or portion sizes to students in different grade
groups.
[If school includes the following grade group combinations: K-5 and 6-8; K-5 and 9-12; 6-8 and 9-12; or K5, 6-8, and 9-12, ask the following questions:]
Reimbursable Foods Form for Lunch
1.
For reimbursable lunches, does your school offer the same menu to all students—meaning the same
foods and portion sizes—or does your school ever offer different foods and/or portion sizes to
students in different grade groups?
MARK ONE
1
2
□ School offers the same menu to all students (same foods and portion sizes).
□ School sometimes offers different foods and/or portion sizes to students in different grade
groups.
[If Q1 = 1, end; If Q1 = 2, ask Q2a]
2a. For reimbursable lunches, does your school ever offer different types of foods to students in different
grades (for example, younger students get tacos and older students get burritos)?
1
0
□
□
Yes
No
1
[If Q2a = Yes, ask Q2b; if Q2a = No, ask Q3a]
2b. For each of the following categories of foods, please indicate whether your school offers different
foods to different grade groups of students for reimbursable lunches.
MARK ONE PER ROW
YES
a. Milk
1
b. 100% fruit juices
1
c.
1
Fruits (excluding juice)
d. Vegetables
1
e. Entrée or meat/meat alternate items (such as sandwiches, pizza, entrée
salads, chicken tenders, cheese sticks)
f. Bread and grain items offered separately (such as crackers,
croutons, rolls, tortilla chips)
1
1
g. Desserts, drinks, and snack items (such as cookies, fruit drinks, Jello)
1
h. Condiments and salad dressings
1
□
□
□
□
□
□
□
□
NO
0
0
0
0
0
0
0
0
□
□
□
□
□
□
□
□
3a. For reimbursable lunches, does your school ever offer different portion sizes of the same food to
students in different grades (for example, younger students get 3 oz burritos and older students get
5 oz burritos)?
1
0
□
□
Yes
No
[If Q3a = No, skip to Q5]
3b. For each of the following categories of foods, please indicate whether your school offers different
portion sizes to different grade groups of students for reimbursable lunches.
MARK ONE PER ROW
YES
NO
a. Milk
1
□
0
□
b. 100% fruit juices
1
□
0
□
c.
1
□
0
□
d. Vegetables
1
□
0
□
e. Entrée or meat/meat alternate items (such as sandwiches, pasta, pizza,
entrée salads, chicken tenders, cheese sticks)
1
□
0
□
Bread and grain items offered separately (such as crackers,
croutons, rolls, tortilla chips)
1
□
0
□
g. Desserts, drinks, and snack items (such as cookies, fruit drinks,
Jello/gelatin)
1
□
0
□
h. Condiments and salad dressings
1
□
0
□
f.
Fruits (excluding juice)
2
[If Q2b or Q3b = Yes for a food category: When completing the Reimbursable Foods Form each day, the
SNM will indicate for each food under that food category: (1) which grade group(s) each food is offered to,
and (2) whether the food is offered in different portion sizes. For foods offered in different portion sizes,
the SNM will enter separate portion sizes for each relevant grade group.]
[If Q3a = Yes (offer different portion sizes)]
4.
For foods that are offered in different portion sizes, do you track how many servings of each portion
size were served to each grade group?
1
0
□
□
Yes
No
[If Q4 = Yes (track each portion size separately), SNM will be asked to report number of portions data
separately for each portion size for a given food. If Q4 = No (do not track each portion size separately),
SNM will be asked to report number of portions data across all available portion sizes.]
5.
On an average day, how many reimbursable lunches do you serve to students in each grade group?
[DISPLAY GRADE GROUPS FOR SCHOOL]
____ Students in grades K to 5
____ Students in grades 6 to 8
____ Students in grades 9 to 12
□ Don’t know
[Note: If Q4 = No (do not track each portion size separately), we will use data from Q5 to allocate the
combined number of portions data for a given food to the individual portion size associated with each
grade group. If Q5 = Don’t know, we attempt to get enrollment data by grade group to do this allocation.]
Reimbursable Foods Form for Breakfast
1.
For reimbursable breakfasts, does your school offer the same menu to all students—meaning the
same foods and portion sizes—or does your school ever offer different foods and/or portion sizes to
students in different grade groups?
MARK ONE
1
2
□ School offers the same menu to all students (same foods and portion sizes).
□ School sometimes offers different foods and/or portion sizes to students in different grade
groups.
[If Q1 = 1, end; If Q1 = 2, ask Q2a]
2a. For reimbursable breakfasts, does your school offer different types of foods to students in different
grades (for example, younger students get cereal and older students get muffins)?
1
0
□
□
Yes
No
3
[If Q2a = Yes, ask Q2b; if Q2a = No, ask Q3a]
2b. For each of the following categories of foods, please indicate whether your school offers different
foods to different grade groups of students for reimbursable breakfasts.
MARK ONE PER ROW
YES
a. Milk
1
b. 100% juice
1
c.
1
Fruits and vegetables (excluding juice)
d. Breakfast entrées and bread and grain items (such as breakfast
pizzas, sandwiches, cold or hot cereal, pancakes, French toast)
1
e. Meat/meat alternate items (such as eggs, sausage, yogurt)
1
f.
1
Condiments
□
□
□
□
□
□
NO
0
0
0
0
0
0
□
□
□
□
□
□
3a. For reimbursable breakfasts, does your school offer different portion sizes of the same food to
students in different grade (for example, younger students get 1 oz muffin and older students get 2
oz muffin).
1
0
□
□
Yes
No
[If Q3a = No, skip to Q5]
3b. For each of the following categories of foods, please indicate whether your school offers different
portion sizes to different grade groups of students for reimbursable breakfasts.
MARK ONE PER ROW
YES
a. Milk
b. 100% juice
c.
Fruits and vegetables (excluding juice)
d. Breakfast entrées and bread and grain items (such as breakfast
pizzas, sandwiches, cold or hot cereal, pancakes, French toast)
e. Meat/meat alternate items (such as eggs, sausage, yogurt)
f.
Condiments
NO
1
□
0
□
1
□
0
□
1
□
0
□
1
□
0
□
1
□
0
□
1
□
0
□
[If Q2b or Q3b = Yes for a food category: When completing the Reimbursable foods Form each day, the
SNM will indicate for each food under that food category: (1) which grade group(s) each food is offered to,
and (2) whether the food is offered in different portion sizes. For foods offered in different portion sizes,
the SNM will enter separate portion sizes for each relevant grade group.]
[If Q3a = Yes (offer different portion sizes)]
4
4.
For foods that are offered in different portion sizes, do you track how many servings of each portion
size were served to each grade group?
1
0
□
□
Yes
No
[If Q4 = Yes (track each portion size separately), SNM will be asked to report number of portions data
separately for each portion size for a given food. If Q4 = No (do not track each portion size separately),
SNM will be asked to report number of portions data across all available portion sizes.]
5.
On an average day, how many reimbursable breakfasts do you serve to students in each grade
group?
[DISPLAY GRADE GROUPS FOR SCHOOL]
____ Students in grades K to 5
____ Students in grades 6 to 8
____ Students in grades 9 to 12
□ Don’t know
[Note: If Q4 = No (do not track each portion size separately), we will use data from Q5 to allocate the
combined number of portions data for a given food to the individual portion size associated with each
grade group. If Q5 = Don’t know, we attempt to get enrollment data by grade group to do this allocation.]
5
OMB Clearance Number: 0584-xxxx
Expiration Date: xx/xx/20xx
EMS Foods Paired/Offered Together Module
and Food Bar Questions (Group 2a, Group 3, FOA)
Note: The Electronic Menu Survey (EMS) will include additional questions that collect information needed
for the compliance assessment. This includes the “Foods paired/offered together” module in the
Reimbursable Foods Forms (for lunch and breakfast) and questions about salad bars.
1.
EMS FOODS PAIRED/OFFERED TOGETHER MODULE
The Reimbursable Foods Forms in the EMS will include a “foods paired/offered together” module.
After the school nutrition manager (SNM) reports all foods that were offered on a given day (and
associated food details), she will be taken to the “foods paired/offered together” module. The module
will be programmed to ask questions based on the specific foods reported on a given day.
If the menu day includes any separate grain items (for example, rice, rolls, or crackers) or any
meat/meat alternate items (for example, yogurt, string cheese, peanut butter), the SNM will be
asked if the item is served only with another item. If the SNM answers “yes”, they will be asked
to “pair” the items together (for example, the crackers were available only with the Chef’s salad).
After pairing items together, if 2 or more separate grain items or 2 or more separate meat/meat
alternate items are left “unpaired” the SNM will be asked how many of the “unpaired” items
students can select (separately for grains and meats/meat alternates).
2.
FOOD BAR QUESTIONS
If a side salad bar or entrée salad bar is reported, the EMS will ask the SNM a follow-up question
regarding the rules for visiting the bar.
[If Reimbursable Foods Form includes side salad bar, ask:]
Can students visit the side salad bar in addition to choosing other fruit or vegetable choices?
-
Yes, students can take fruits and vegetables from the side salad bar and also choose other fruits
and vegetables offered outside of the bar.
-
No, students can either visit the side salad bar OR take other fruit and vegetable choices offered
outside of the bar (but not both).
[If Reimbursable Foods Form includes entrée salad bar, ask]:
Can all students visit the entrée salad bar in addition to taking another entrée choice, or is the bar
considered a separate entrée choice?
-
All students can visit the entrée salad bar and also take another entrée choice.
-
Students can either visit the entrée salad bar OR take a different entrée choice offered outside of
the bar (but not both).
6
| File Type | application/pdf |
| Subject | Instructions |
| Author | Denise Mercury, Liz Condon |
| File Modified | 2024-02-28 |
| File Created | 2024-02-28 |