SNMCS State, Local & Tribal Governments

APPENDIX I

Group 2—FSM Request for Data on Reimbursable Meal Sales

This page has been left blank for double-sided copying.

R

OMB Clearance Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

equest for Data on Reimbursable Meal Sales

School Name:

School Mathematica ID # | | | | | | | | |

Interviewer Mathematica ID # | | | | | | | | |

1. PROVIDE SCHOOL FOODSERVICE STAFF WITH THE LIST OF NAMES AND IDS AND THE TARGET DATE FOR EACH SAMPLED STUDENT.

2. ASK FOODSERVICE STAFF TO COMPLETE THE ATTACHED FORM, OR PROVIDE SCHOOL RECORDS THAT INCLUDE THE REQUESTED INFORMATION.

3. INDICATE THE STATUS OF THE REQUEST BELOW.

□ Complete records were provided by the school

□ Partial records were provided by the school (Describe reason and plans for follow up)

□ No records were provided by the school (Describe reason and plans for follow up)

According to the Paperwork Reduction Act of 1995, no persons are 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 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Request for Data on Reimbursable Meal Sales

School Name:

School Mathematica ID # | | | | | | | | |

Student Name	Target date	Student ID	Reimbursable lunch taken on target date (yes/no)	Reimbursable breakfast taken on target date (yes/no)	Certification Status (Free, reduced price, paid)
Example Joe Smith	5/1/13	555555	Yes	No	Reduced price