School Nutrition Dietary Assessment Study - IV

appendix C

MENU SURVEY FORMS

School Nutrition Dietary

Assessment Study IV

(OMB No.: 0584-0527)

Note: These forms are provided to respondents in an organized packet that includes a separate instruction manual (Appendix D). The approved public burden statement appears on the cover of the instruction manual.

Project Officer: Fred S. Lesnett

Office: Office of Research and Analysis

Food and Nutrition Service

Room 1014

3101 Park Center Drive

Alexandria, VA 22302

Telephone: 703-605-0811

FAX: 703-305-2576

Email: Fred.Lesnett@FNS.USDA.GOV

D

OMB Clearance Number: 0584-0527

Expiration Date: xx/xx/xxxx

aily Meal Counts Form

School Name:

Date:

Instructions:

1. In the boxes for Reimbursable Lunches and Reimbursable Breakfasts, please record the number of USDA 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.

2. Check if the number of reimbursable meals was much higher or lower than usual. If so, describe the reasons for this difference in the space provided.

3. At the bottom of the page, please record the total value of your a la carte sales for each day of the target week.

Number of Reimbursable Lunches Served
Day of Week	USDA Free	USDA Reduced- Price	Full- Price	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 Breakfasts Served
Day of Week	USDA Free	USDA Reduced- Price	Full- Price	for office use only	Please check if the number of reimbursable breakfasts served this day was much higher or lower than usual.
Monday					 Reason:_______________________________
Tuesday					 Reason:_______________________________
Wednesday					 Reason:_______________________________
Thursday					 Reason:_______________________________
Friday					 Reason:_______________________________

Total Daily A La Carte Sales
Monday	$_______________
Tuesday	$_______________
Wednesday	$_______________
Thursday	$_______________
Friday	$_______________

S

OMB Clearance Number: 0584-0527

Expiration Date: x/xx/xxxx

CHOOL NUTRITION DIETARY ASSESSMENT STUDY

Reimbursable Foods Form: Lunch

NOTE: For instructions on completing this form, please refer to Instructions for Menu Survey.

School Name:__________________________________ Date:________________________	Day:	1 Mon	2 Tue	3 Wed	4 Thu	5 Fri

A.

B.

C.

D.

E.

F.

G.

H.

Food Item

Portion Size (Incl. Units)

Number of Reim-bursable Portions Served

Total Number of Portions Served

Any Sold a La Carte or to Adults?

Number of a La Carte/ Adult Portions Served

Manufacturer/Brand Name and Product Code (If Applicable)

Food Description

USDA Commodity?

Recipe?

MILK (Note: If more than one size is available, list separately in “Other Menu Items” section.)

White, whole

fl oz.



White, 2%

fl oz.



White, 1%

fl oz.



White, fat-free/skim

fl oz.



Chocolate

fl oz.



Specify fat content:

Other type/flavor (Specify)__________________________

fl oz.



Specify fat content:

Other type/flavor (Specify)__________________________

fl oz.



Specify fat content:

FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, list as separate item and complete RECIPE FORM.)

Apple, fresh





Applesauce, canned

cup



 Sweetened

 Unsweetened



Banana, fresh



Fruit cocktail, canned

cup



 Heavy syrup  Juice

 Light syrup  Water



Orange, fresh





Peaches, canned

cup



 Heavy syrup  Juice

 Light syrup  Water



Pears, fresh





Pears, canned

cup



 Heavy syrup  Juice

 Light syrup  Water



Pineapple, canned

cup



 Heavy syrup  Juice

 Light syrup  Water









JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and vegetable juice. Fruit drinks are included in ‘Desserts, Drinks, and Snacks’ section.)

Orange juice

fl oz.



 Vitamin C added  Calcium added



Apple juice

fl oz.



 Vitamin C added  Calcium added



Frozen juice cup/bar

fl oz.



 Vitamin C added  Calcium added

fl oz.



 Vitamin C added  Calcium added



VEGETABLES

Beans, green

cup



 Fresh  Frozen  Canned Fat added:  Yes  No If yes, specify type:



Broccoli

cup



 Fresh  Frozen  Canned Fat added:  Yes  No If yes, specify type:

Carrot sticks



If offered, list dip as separate item(s) or complete RECIPE FORM



Corn, kernels

cup



 Fresh  Frozen  Canned Fat added:  Yes  No If yes, specify type:



French fries

oz.



 Oven-baked  Deep-fried



Peas, green

cup



 Fresh  Frozen  Canned Fat added:  Yes  No If yes, specify type:



Potatoes, whipped or mashed

cup



 From fresh If prepared with fat and/or milk, complete RECIPE FORM





Salad bar (non-entrée or small portion)

Self-serve



Please list all ingredients on SELF‑SERVE/MADE-TO-ORDER BAR FORM

Salad, tossed

cup



List dressing as separate item(s) or complete RECIPE FORM



Tater tots or shapes

oz.



 Oven-baked  Deep-fried

















ENTREES OTHER THAN SANDWICHES AND SELF-SERVE BARS (Note: If entrée item is commercially prepared, complete Column E. For items prepared from scratch, fill out a RECIPE FORM.)

Burrito

oz.



Specify fillings:



Chef's salad

1 salad





Chicken, piece(s) (Specify part)______________________ (Specify part)______________________



Breaded:  Yes  No With skin:  Yes  No  Oven-baked  Deep-fried





Chicken nuggets

ea.



 Oven-baked  Deep-fried Weight of each nugget: oz.



Chicken patty (not sandwich)

oz.



Breaded:  Yes  No  Oven-baked  Deep-fried



Corndog

oz.



 All beef  Beef &  Turkey or Pork Chicken

Ham, slice

oz.



 Pork  Turkey



Pizza, cheese

oz.



 Extra cheese  Stuffed crust



Pizza, pepperoni

oz.



 Extra cheese  Stuffed crust



Pizza, sausage

oz.



 Extra cheese  Stuffed crust



Spaghetti with meat sauce

cup





Taco



 Hard shell  Soft tortilla Specify fillings:



Turkey, slice

oz.



Yogurt (as meat alternate)

oz.



Specify flavors:  Regular  Low-fat  Fat-free  Low-cal sweetener







SANDWICHES: (Note: If a sandwich is commercially prepared, fill out manufacturer/brand and product code (Column E). For items prepared from scratch, complete a RECIPE FORM or record information for each sandwich below, including type and weight of bread; type and amount of filling; type and amount of any additions. See Instruction Manual for examples.)

Sandwich/deli bar

Self-serve



Please list all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

Cheese, grilled

1 sandwich





Cheeseburger

1 sandwich





Chicken filet or breast (not breaded)

1 sandwich





Chicken patty (breaded)

1 sandwich





Ham and cheese

1 sandwich





Hamburger

1 sandwich





Hot dog

1 sandwich





Italian sub

1 sandwich





Peanut butter & jelly

1 sandwich





Rib, barbeque

1 sandwich





Turkey

1 sandwich





Tuna salad

1 sandwich





1 sandwich





1 sandwich





1 sandwich





1 sandwich





1 sandwich





1 sandwich





SELF-SERVE ENTRÉE BARS

Entrée salad bar (or large portion)

Self-serve



Please list all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

Potato bar

Self-serve



Please list all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

Nacho/taco bar

Self-serve



Please list all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

Self-serve



Please list all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

Self-serve



Please list all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

BREADS AND GRAINS OFFERED SEPARATELY

Biscuit

oz.



 Whole grain



Bread, plain

oz.



Type:  Whole grain

Bread, buttered

oz.



Type:  Whole grain  Margarine  Butter



Breadstick

oz.



Type:  Whole grain



Cornbread

oz.





Crackers

ea.



Type:  Whole grain

Rice

cup



 White  Brown





Roll

oz.



Type:  Whole grain



Pasta

cup



Type:  Whole grain





























DESSERTS, DRINKS, AND SNACKS OFFERED AS PART OF A REIMBURSABLE MEAL

Brownie





Cake



Specify type:



Cookie

oz.



Specify type:



Fruit drink

fl oz.



Specify type: Specify % juice content:

Gelatin, plain

cup



Gelatin, with fruit

cup





Potato chips

oz.



Specify type:

Yogurt

oz.



Specify flavors:  Regular  Low-fat  Fat-free  Low-cal sweetener

















SALAD DRESSINGS

French dressing



 Reg  Light  Red calorie  Fat-free



Italian dressing



 Reg  Light  Red calorie  Fat-free



Ranch dressing



 Reg  Light  Red calorie  Fat-free





 Reg  Light  Red calorie  Fat-free





 Reg  Light  Red calorie  Fat-free





 Reg  Light  Red calorie  Fat-free





 Reg  Light  Red calorie  Fat-free





 Reg  Light  Red calorie  Fat-free





 Reg  Light  Red calorie  Fat-free





 Reg  Light  Red calorie  Fat-free



OTHER CONDIMENTS



Self-serve condiments or fixins’ bar

Self-serve



Please list all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM

Barbeque sauce





Butter



Cream cheese



 Reg  Red fat  Light  Fat-free

Gravy



 Reg  Red fat  Low-fat  Fat-free



Honey



Ketchup



Margarine



Mayonnaise



 Reg  Light  Low-fat  Fat-free

Mustard



Tartar sauce



 Reg  Red fat  Low-fat  Fat-free



Peppers, jalapeno



Pickles, relish



Pickles, slices



Ranch dip



 Reg  Light  Red calorie  Fat-free



Salsa







Sour cream



 Reg  Red fat  Light  Fat-free

















































OTHER MENU ITEMS



























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







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





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S

OMB Clearance Number: 0584-0527

Expiration Date: xx/xx/xxxx

CHOOL NUTRITION DIETARY ASSESSMENT STUDY

Reimbursable Foods Form: Breakfast

NOTE: For instructions on completing this form, please refer to Instructions for Menu Survey.

School Name:__________________________________ Date:________________________	Day:	1 Mon	2 Tue	3 Wed	4 Thu	5 Fri

A.	B.	C.	D.					E.	F.	G.	H.
Food Item	Portion Size (Incl. Units)	Number of Reim-bursable Portions Served	Total Number of Portions Served		Any Sold a La Carte or to Adults?		Number of a La Carte/ Adult Portions Served	Manufacturer/Brand Name and Product Code (If Applicable)	Food Description	USDA Commodity?	Recipe?
MILK (Note: If more than one size is available, list separately in “Other Menu Items” section.)
White, whole	fl oz.				
White, 2%	fl oz.				
White, 1%	fl oz.				
White, fat-free/skim	fl oz.				
Chocolate	fl oz.								Specify fat content:
Other type/flavor (Specify)__________________	fl oz.								Specify fat content:
Other type/flavor (Specify)__________________	fl oz.								Specify fat content:
	fl oz.								Specify fat content:
FRUIT (Note: Prelisted entries should be used only for fruit that is served as purchased. If anything is added before serving, list as separate item and complete RECIPE FORM.)
Apple, fresh										
Banana, fresh					
Grapefruit, fresh
Grapes, fresh					
Orange, fresh										
Peaches, canned	cup								 Heavy syrup  Light syrup  Juice  Water	
											
											
JUICES (Note: Prelisted entries should be used only for full-strength (100%) fruit and vegetable juice. Fruit drinks are included in ‘Desserts, Drinks, and Snacks’ section.)
Orange juice	fl oz.								 Vitamin C added  Calcium added	
Apple juice	fl oz.								 Vitamin C added  Calcium added	
	fl oz.								 Vitamin C added  Calcium added	
	fl oz.								 Vitamin C added  Calcium added	
COLD CEREALS
Apple Jacks	oz.				
Cheerios, plain	oz.				
Cheerios, Honey Nut	oz.				
Cinn Toast Crunch	oz.				
Cocoa Krispies	oz.				
Cocoa Puffs	oz.				
Froot Loops	oz.				
Frosted Flakes	oz.				
Golden Grahams	oz.				
Lucky Charms	oz.				
Rice Krispies	oz.				
Special K	oz.				
Trix	oz.				
Wheaties	oz.				
	oz.										
	oz.										
HOT CEREALS (Note: If prepared with fat and/or milk, complete RECIPE FORM)
Cream of Wheat	cup								 Instant  Quick  Reg		
Grits	cup								 Instant  Quick  Reg		
Oatmeal	cup								 Instant  Quick  Reg		
OTHER BREADS AND GRAINS OFFERED SEPARATELY
Bagel	oz.								Type:  Whole grain
Biscuit	oz.								 Whole grain		
Doughnut	oz.								 Icing/glaze  No icing/glaze
English muffin, plain	oz.								Type:  Whole grain
English muffin, buttered	oz.								Type:  Whole grain  Margarine  Butter		
Granola/cereal bar	oz.								Specify type:
Muffin	oz.								Specify type:		
Pancake	oz.										
Roll, cinnamon	oz.								 Icing  No icing		
Toast, plain	oz.								Type:  Whole grain
Toast, buttered	oz.								Type:  Whole grain  Margarine  Butter		
Toaster pastry	oz.			
											
MEATS AND MEAT ALTERNATES OFFERED SEPARATELY
Bacon	sl								 Pork  Turkey
Eggs	cup ea.								 Boiled  Fried  Scrambled If prepared with fat and/or milk, complete RECIPE FORM		
Ham	oz.								 Pork  Turkey	
Sausage	oz.								 Pork  Turkey  Beef
Yogurt	oz.								Specify flavors:  Regular  Low-fat  Fat-free  Low-cal sweetener
											
											
COMBINATION BREAD/MEAT ITEMS (Note: If item is commercially prepared, complete Column E. For items prepared from scratch, fill out a RECIPE FORM.)
Breakfast burrito	oz.								Specify fillings:		
Cheese sandwich, toasted	1 sandwich										
Egg sandwich	oz. 1 sandwich								 Cheese  Sausage  Ham  Bacon  Other: ______________		
Egg sandwich	oz. 1 sandwich								 Cheese  Sausage  Ham  Bacon  Other: ______________		
French toast											
French toast sticks	ea.								Weight of each stick: oz.
Pancake on a stick	oz.				
Pizza	oz.								Specify toppings:		
											
CONDIMENTS
Self-serve condiments or fixins’ bar	Self-serve							Please list all ingredients on SELF-SERVE/MADE-TO-ORDER BAR FORM
Butter					
Cream cheese									 Reg  Red fat  Light  Fat-free
Gravy									 Reg  Red fat  Low-fat  Fat-free		
Jelly					
Ketchup					
Margarine					
Salsa											
Syrup									 Reg  Light  Red calorie  Sugar-free		
											
											
											
OTHER MENU ITEMS
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S

OMB Clearance Number: 0584-0527

Expiration Date: xx/xx/xxxx

elf-Serve/Made-to-Order Bar Form

School Name:

Name of Bar:

Meal:

1  Breakfast

2  Lunch

Day:

1All

2Mon

3Tue

4Wed

5Thu

6Fri

A.	B.	C.	D.	E.	F.
Food Name	Portion Size, If Pre‑portioned (Include units)	Manufacturer/ Brand Name and Product Code (if applicable)	Food Description	USDA Commodity?	Recipe?
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R

OMB Clearance Number: 0584-0527

Expiration Date: xx/xx/xxxx

ecipe Form

School Name:							Recipe/Food Name:
Meal:	1  Breakfast		2  Lunch
Day:	1  Mon	2  Tue		3  Wed	4  Thu	5  Fri	Size of One Serving (include units):
	6  All						Number of Servings Prepared:

A.	B.	C.	D.	E.	F.
Ingredient Name	Amount in Recipe (Include units)	Manufacturer/ Brand Name and Product Code (If applicable)	Ingredient Description	USDA Commodity?	Recipe?
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OMB Clearance Number: 0584-0527

Expiration Date: xx/xx/xxxx

S CHOOL NUTRITION DIETARY ASSESSMENT STUDY

A La Carte Foods Checklist

SCHOOL NAME: _________________________________________

DATE COMPLETED: | | | /| | | /| | | | |

Month Day Year

1. Does your school sell food or beverages on an a la carte basis?

1  Yes

0  No Thank you. You are done.

2. When does your school sell food or beverages on an a la carte basis?

1  During breakfast only

2  During lunch only

3  During breakfast and lunch

Please refer to the Instructions for Menu Survey for instructions on completing this form. Remember to include this form when you return the Menu Survey Folder with all completed survey materials.

SCHOOL NUTRITION DIETARY ASSESSMENT STUDY

A La Carte Checklist

Food Item	Breakfast	Lunch
A. Milk
1. Whole white milk	1 	1 
2. Reduced fat (2%) white milk	2 	2 
3. Low-fat (1%) white milk	3 	3 
4. Fat-free/skim white milk	4 	4 
5. Reduced fat (2%) flavored milk	5 	5 
6. Low-fat (1%) flavored milk	6 	6 
7. Fat-free/skim flavored milk	7 	7 
B. Fruit/Juice
1. Dried fruit (such as raisins or apricots)	8 	8 
2. Canned fruit	9 	9 
3. Fresh fruit	10 	10 
4. Juice (100% fruit or vegetable juice)	11 	11 
C. Vegetables
1. French fries - baked (including tater tots)	12 	12 
2. French fries - deep-fried (including tater tots)	13 	13 
3. Potatoes (other than french fries/tater tots)	14 	14 
4. Corn	15 	15 
5. Carrots (cooked)	16 	16 
6. Other cooked vegetables (Specify)	17 	17 
a.	18 	18 
b.	19 	19 
c.	20 	20 
7. Raw vegetables	21 	21 
8. Tossed salads (side)	22 	22 
9. Prepared salads (such as potato salad, coleslaw, or three bean salad)	23 	23 
10. Vegetable soup	24 	24 
D. Bread/Grains
1. Regular bread, rolls, bagels, or tortillas	25 	25 
2. Whole grain bread, rolls, bagels, or tortillas	26 	26 
3. Other bread items (such as biscuits, croissants, or hot pretzels)	27 	27 
4. Low-fat muffins	28 	28 
5. Regular muffins	29 	29 
6. Ready-to-eat breakfast cereal	30 	30 
7. Pancakes, waffles, or French toast	31 	31 
E. Meat/Meat Alternates
1. Breaded chicken/turkey (nuggets, patties, strips, parts)	32 	32 
2. Not breaded chicken/turkey (nuggets, patties, strips, parts)	33 	33 
3. Breaded beef/pork (nuggets, patties, strips)	34 	34 
4. Not breaded beef/pork (nuggets, patties, strips)	35 	35 
5. Sausage or bacon	36 	36 
6. Breaded fish (nuggets, patties, strips/sticks)	37 	37 
7. Not breaded fish (nuggets, patties, strips/sticks, fillets)	38 	38 
8. Eggs	39 	39 
9. Cheese	40 	40 
10. Chili	41 	41 
F. Entrees
sandwiches
1. Cheeseburger or hamburger	42 	42 
2. Hot dog or corn dog	43 	43 
3. Peanut butter sandwich (including with jelly)	44 	44 
4. Cheese sandwich	45 	45 
5. Sandwich with breaded meat, poultry or fish	46 	46 
6. Sandwich with cold cuts (salami, bologna, or pepperoni)	47 	47 
7. Sandwich with plain (not breaded) meat, poultry or fish	48 	48 
8. Egg sandwich or breakfast burrito	49 	49 
9. Other sandwiches (Specify)	50 	50 
a.	51 	51 
b.	52 	52 
c.	53 	53 
Other Entrees
10. Pizza without meat	54 	54 
11. Pizza with meat	55 	55 
12. Burritos	56 	56 
13. Other Mexican foods (such as tacos, nachos, or quesadillas)	57 	57 
14. Chinese food	58 	58 
15. Lasagna	59 	59 
16. Spaghetti	60 	60 
17. Macaroni and cheese	61 	61 
18. Entrée salad (such as chef’s, cob, or chicken Caesar)	62 	62 
19 Soup with meat or beans (such as chicken, clam chowder, or minestrone)	63 	63 
20. Other entrees (Specify)	64 	64 
a.	65 	65 
b.	66 	66 
G. Beverages Other than Milk or 100% Juice
1. Diet carbonated soft drink (diet soda/pop)	67 	67 
2. Regular carbonated soft drink (regular soda/pop)	68 	68 
3. Juice drinks and other sweetened drinks (such as cranberry drink, fruit blends, Hi‑C, lemonade, punch, iced tea)	69 	69 
4. Energy and sports drinks (such as Gatorade, PowerAde, Red Bull, Vitamin Water)	70 	70 
5. Bottled water (plain, flavored, or sparkling)	71 	71 
6. Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)	72 	72 
H. Baked Goods
1. Low-fat/reduced-fat cakes, cupcakes, or brownies	73 	73 
2. Regular cakes, cupcakes, or brownies	74 	74 
3. Low-fat pies, turnovers, or toaster pastries	75 	75 
4. Regular pies, turnovers, or toaster pasties	76 	76 
5. Doughnuts	77 	77 
6. Low-fat cookies	78 	78 
7. Regular cookies	79 	79 
I. Frozen/Dairy Dessert
1. Frozen fruit bars or popsicles	80 	80 
2. Milkshakes, smoothies, or yogurt drinks	81 	81 
3. Low-fat/reduced-fat ice cream, frozen yogurt, or sherbet	82 	82 
4. Regular ice cream, frozen yogurt, or sherbet	83 	83 
5. Pudding	84 	84 
J. Snacks
1. Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	85 	85 
2. Regular chips (such as corn, potato, puffed cheese, tortilla, or snack mixes)	86 	86 
3. Pretzels	87 	87 
4. Popcorn	88 	88 
5. Cracker sandwiches with cheese or peanut butter	89 	89 
6. Other types of crackers (including animal crackers)	90 	90 
7. Low-fat/reduced-fat granola bars, cereal bars, or energy bars	91 	91 
8. Regular granola bars, cereal bars, or energy bars	92 	92 
9. Crispy rice bars or treats	93 	93 
10. Yogurt	94 	94 
11. Candy	95 	95 
12. Gum	96 	96 
13. Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)	97 	97 
14. Fruit snacks (such as Fruit Roll-Ups or fruit leather)	98 	98 
15. Meat snacks (such as jerky or pork rinds)	99 	99 
K. Other a La Carte Items (Specify)
Please list any food or beverage that is not listed in sections A-J of this checklist that the cafeteria offered a la carte on the day you complete this form
	100 	100 
	101 	101 
	102 	102 
	103 	103 
	104 	104 
	105 	105 
	106 	106 
	107 	107 
	108 	108 
	109 	109 
	110 	110 
	111 	111 
	112 	112 
	113 	113 
	114 	114 

SCHOOL NUTRITION DIETARY ASSESSMENT STUDY

Afterschool Snack Form

NOTE: For instructions on completing this form, please refer to Instructions for Completing the Afterschool Snack Form.

School Name:_____________________________________ Date:______________________________

A.	B.	C.	D.	E.
Food Item	Portion Size (Incl. Units)	Number of Portions Prepared/ Available	Number of Portions Served to Students	Number of Reimbursable Snacks Served
Monday
Tuesday
Wednesday
Thursday
Friday

Prepared by Mathematica Policy Research, Inc.