SNMCS State, Local & Tribal Governments

P2. GROUP 2—POINT OF SALE FORM (INTERVIEWER-COMPLETED)

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P

OMB Clearance Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

OINT OF SALE FORM

School Name:

School ID:

Date:

Mark the source of Information

Mark the times at which POS is available

Mark the proportion of foods sold at POS that is reimbursable for . . .

AMPM Source Screen Codes

Breakfast

Lunch

Name of POS

Location of POS (Check if present)

Observed

School staff

Breakfast

Lunch

Other Times

All

Most

About Half

Small Amount

None

All

Most

About Half

Small Amount

None

31

Vending Machine(s)

□ In cafeteria (indoor or outdoor seating/eating area)

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□

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32

Vending Machine(s)

□ Outside but near (within 20 feet) cafeteria

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33

Vending Machine(s)

□ In other location on school grounds

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34

Cafeteria line(s) - Reimbursable items only

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35

Cafeteria line(s) - A La Carte items only

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36

School Store

□

□

□

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37

Snack Bar(s) – A La Carte Items only

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38

Classroom (breakfast)

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39

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40

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41

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42

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43

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44

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45

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91 (Other)

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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 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.