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pdfE1.1 BASIC MENU SURVEY BOOKLET: INSTRUCTIONS, EXAMPLE
FORMS, AND FORMS (GROUP 2)
Menu Survey Screener - Basic (Group 2)
Daily Meal Counts Form (Group 2)
Reimbursable Foods Form - Breakfast (Group 2)
Reimbursable Foods Form - Lunch (Group 2)
Recipe Form (Group 2)
Self-Serve/Made to Order Bar Form (Group 2)
NSLP Afterschool Snack Form (Group 2)
Menu Survey Enhancements Administered through the Electronic
Menu Survey (EMS) (Group 2)
A la Carte Foods Checklist (Group 2)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
School Nutrition and Meal Cost
Study-II
Instructions for the
Menu Survey (Basic)
Sponsored by:
U.S. Department of Agriculture
Food and Nutrition Service
The Basic Menu Survey will be administered as a booklet that contains each of the instruments listed on the appendix page. Therefore,
the total burden for all instruments in the Basic Menu Survey is included in the burden statement below.
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 8 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, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA
(0584-xxxx). Do not return the completed form to this address.
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INSTRUCTIONS FOR THE MENU SURVEY (BASIC)
INTRODUCTION TO THE MENU SURVEY
Thank you for participating in the School Nutrition and Meal Cost Study-II. 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, sold a la carte, and in afterschool snacks (if reimbursed through the
National School Lunch Program). 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.
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.
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 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.
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INSTRUCTIONS FOR BASIC MENU SURVEY
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 from
scratch or 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.
A La Carte Foods Checklist
The A La Carte Foods Checklist is a multiple-page form (pink paper) that you will use to
identify all foods and beverages sold on an a la carte basis in your school. You only need
to fill out this form for ONE DAY OF THE WEEK. The day of the week that has been
randomly selected to be your “a la carte checklist day” is shown on the front cover of the
form.
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 BASIC 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 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.
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 BASIC 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, left over, and wasted.
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 right-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 BASIC 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 offered only a la carte or only to adults.
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 BASIC 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 BASIC 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 served to students in reimbursable
meals, served 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 four sub-columns (Reimbursable
Served, Served 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 all portions that
are prepared for your school for reimbursable meals as well portions that are prepared to
be served for a la carte and to adults or 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.
Reimbursable Portions Served
For each menu item, enter the number of reimbursable portions served to students
(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.
Portions Served A La Carte or to Adults/Others
Also for each menu item, enter the number of portions that are served a la carte, to adults,
or to others who are not receiving meals through the NSLP or SBP. If no portions are
served a la carte or to adults/others, enter zero in this column.
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INSTRUCTIONS FOR BASIC MENU SURVEY
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 leftover 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 leftover 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 four sub-columns (Reimbursable Served, Served 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
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over
for Later
Use
Wasted
Orange juice
8 fl. oz.
140
120
10
10
0
Macaroni and
cheese
1 cup
160
140
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 BASIC 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 BASIC 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, blueberry muffin, unbreaded chicken
patty, low-sodium green beans)
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)
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 from
scratch or 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 prepared from scratch
or 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 BASIC MENU SURVEY
Instructions for Completing the
Recipe Forms
Purpose:
To describe the types and amounts of ingredients used in preparing foods
made from scratch or 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 13).
A recipe is needed for every item that is prepared from scratch or 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 BASIC 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 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 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 BASIC 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, low-sodium tomato sauce)
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)
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 BASIC 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, as well as 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 (with all the same
foods/ingredients) was offered more than once during the target week, you
only need to fill out one Self-Serve/Made-to-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.
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INSTRUCTIONS FOR BASIC 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,
low-sodium green beans, 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)
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.
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INSTRUCTIONS FOR BASIC MENU SURVEY
Instructions for Completing the
NSLP Afterschool Snack Form
Purpose:
To describe the foods and beverages offered in NSLP afterschool snacks
during the target week, and to provide information on the number of
individual snack items served and the total number of reimbursable snacks
served to students.
Location:
A booklet of NSLP Afterschool Snack Forms (green paper) is behind the
“Afterschool Snacks” tab in the Menu Survey Folder.
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 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 Afterschool Snack Form
On the front page of this booklet answer question 1 and indicate the days during the target
week that 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 size, number of reimbursable portions prepared/available and served, and
food description so that an accurate nutrient analysis can be done. 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.
Number of Reimbursable Snacks Served
At the top of the form, record the total number of reimbursable snacks served to students
that day.
16
INSTRUCTIONS FOR BASIC MENU SURVEY
Column A: Food Item
You will use this column to identify foods and beverages offered in 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 reimbursable 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
medium
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.
17
INSTRUCTIONS FOR BASIC MENU SURVEY
Example:
A.
B.
C.
Number of Reimbursable
Portions
Portion
Size
(Include
Units)
Prepared/
Available
Served
Orange juice
6 fl.oz.
50
25
Orange juice
8 fl.oz.
50
50
Food Item
Column C: Number of Reimbursable Portions
Number of Reimbursable Portions Prepared/Available
For each snack item offered, write in the number of reimbursable portions
prepared/available. The number of reimbursable portions prepared should reflect the
actual number of servings available for students to select as part of a reimbursable NSLP
afterschool snack.
Number of Reimbursable Portions Served
Also for each 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.
You may need to ask the afterschool program staff for 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.
Column D: 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. Please provide as complete a description of
the item as possible. Depending on the item, this may include information on:
Type (1% or 2% milk; white or whole wheat bread; 100% apple juice)
Form (fresh carrots, canned pineapple)
Flavor (chocolate milk, strawberry yogurt)
Fat or sugar content (low-fat yogurt, reduced-fat cookies; reduced-sugar jelly,
pears in light syrup)
18
INSTRUCTIONS FOR BASIC MENU SURVEY
Instructions for Completing the
A La Carte Foods Checklist
Purpose:
To identify foods and beverages your school offers on an a la carte basis at
lunch and breakfast.
Location:
The A La Carte Foods Checklist (pink paper) is located behind the
“A La Carte” tab in the Menu Survey Folder.
Notes:
Complete the A La Carte Foods Checklist on the one day of the target week
specified on the front of the Menu Survey Folder. Be sure to complete the
checklist even if your school sells only milk on an a la carte basis.
Be sure to look at the sample completed A La Carte Foods Checklist 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 A La Carte Foods Checklist
1. Write the name of your school and the date on the first page of the form.
2. Place a check mark in the box next to each food and beverage that was available
for a la carte purchase on the specified day. This includes items that are sold only
a la carte as well as components of a reimbursable meal that may be purchased a
la carte. There are separate check boxes for lunch and breakfast.
3. If a food or beverage is usually or sometimes available a la carte, but was not
available on the specified day, do not check the box.
4. If your school had a la carte foods or beverages available on your specified day
that are not included in the checklist, please write in the names of these foods and
beverages under the appropriate category. Extra lines are also available on the
last page of the checklist, if necessary. Be sure to indicate whether each food or
beverage was offered at breakfast and/or lunch.
19
0MB Control Number: 0584-xxxx
Expiration Date: xxlxxfxxxx
Daily Meal Counts Form (Basic)
School Name:
Instructions:
1.
2.
Joh Y1
s
W1 ,-+--rt WH d d Le
Date:.__
I -1-/-"'(p---<[i--:;.....
i_o --
D
• Sctiool Nutrition &
Meal Cost Study -11
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.
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 ol Reimbursable NSlP lunches Served
Free
Monday
Tuesday
Wednesday
Thursday
Friday
71-
9 r;-
ReducedPrice
2-�
I 1.
B271
FOR OFFICE
USE ONLY
oO
Please check if the number of reimbursable
lunches served this day was much higher or lower
than usual.
D �Reason:
,r
2 (,
(l·O
FullPrice
□
�Reason:
�
� �Reason: 0IA r1M
23
2 2.
D �Reason:
22
2-S-
□
t>f i & VYl i H
cu
�Reason:
Number 01 Reimbursable SBP Breaklasts 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
I 2..
□
Tuesday
J ·<3
12.
D �Reason:
Wednesday
30
30
3l.
ID
□
�Reason:
32--
I
□
�Reason:
Thursday
Friday
24
3'?
3l
i;-
/D
�Reason:
D �Reason:
0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Reimbursable Meal Counts
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?
j o\rt (l .Srv1 i-rn mid o{ (.e,
School Name:
A.
SCHOOL NUTRITION AND MEAL COST STUDY-II
Reimbursable Foods Form: Breakfast (Basic)
io
1S-
0 __ _
2---=--Date:_I -1-/ _f.o --1-/-=-
8.
:6:
D
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
'lJMon
Day:
□ Tue
□ Thu
□ Wed
Number of Portions
Portion
Size
(Include
Units)
Food Item
MILK
White, fat-free/skim
White, 1%
i
i
fl oz.
fl OZ,
White, 2%
fl OZ.
White, whole
fl oz.
Chocolate, fat-free/skim
i
fl oz.
Chocolate, 1%
fl oz.
Chocolate, 2%
fl oz.
Other flavor
Specify:
S.\-rfA.t,i b-t.rn,,
Other flavor
Specify:
�
� floz.
Total
Prepared
30
Reimbursable
Served
I Cf
Served A La
· Carte or to
Adults/others
(
30
2. (o
z_
2-0
20
0
2-0
ID
0
□ Fri
F.
E.
D.
C.
Schoo: Nldrillon &
Meal Cost Study -11
:t "C
Left Over for
Later Use
lo
2-
0
/D
Wasted
X 0
0 0
al IL
Manufacturer/Brand Name and
Product Code
(If Ann/icab/e)
-
Food Description
()
-"'
G.
�
:t:
X
·.:;
,;i:.
CG
0
0..::
� -g &
:u
u c. E
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0
0
ii'Fat-free/skim
01%
02%
0 Fat-free/skim
01%
02%
O Fat-free/skim
01%
02%
fl OZ.
Other flavor
Specify:
fl oz.
fl oz.
fl OZ.
fl oz.
USDA
-=
0
0
0
0
0
0
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
A.
F.
E.
D.
C.
B.
Number of Portions
Portion
Size
Food Item
FRUIT
(Include
Units)
:t: �
>< 0
0 0
Total
Prepared
Reimbursable
Served
Left Over for
Later Use
Wasted
Manufacturer/Brand Name and
Product Code
--
(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 a RECIP� FORM.)
- -
ADDie, fresh
CUD
Applesauce, canned
Apricots, canned
Banana,fresh
cup
\��{Vttt
cup
Blueberries, frozen
Fruit cocktail, canned
Grapes,fresh
t/ 'L
I/ 'L
cup
cup
so
i5
&,0
Kiwi, raw
Mandarin oranges, canned
'-f
j
32-
59
0
2
'2...
D Unsweetened
D Heavy syrup
D Light syrup
D Extra light syrup D Juice
z.
0
l
0
D
D Sweetened
D Sweetened
D Heavy syrup
□ Water
D Unsweetened
0
f
□
□
□
D
D
□
□
Light syrup
D Heavy syrup
D Extra light syrup D Juice D Water
cup
□
D
D Light syrup
D Heavy syrup
D Extra light syrup D Juice D Water
cup
D
D
D Light syrup
D Heavy syrup
Water
D Extra light syrup D Juice
□
cup
D Heavy syrup
Pineapple, canned
CUD
Raisins
oz.
c.a.n¾ Io c1pe.,
�
li: c. E
.C
D Light syrup
Pears, fresh
Pears, canned
t) c.. J:
:.c: ; (U
ME:xtra light syrup D Juice D Water
Orange, fresh
Peaches, canned
<1 ::>
Q) IJ)
Food Description
·.:;
�-g&
"0
(If Applicable)
2l
:t::
><
.,,_ <(
Ill LL
Served A La
Carte or to
Adults/Others
G.
\ vtllCA �t\}
D Light syrup
D Extra light syrup D Juice
2.-'f>
I e;-
t;'
0
5'
2
.f y-o. ,h
□ Water
D
□
D
□
□
□
□
□
D
0
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
A.
B.
D.
C.
E.
:=
Number of Portions
Portion
Size
(Include
Units)
Food Item
JUICES
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Manufacturer/Brand Name and
Product Code
(If Applicable)
Wasted
4
Grape juice
fl oz.
40
2< 0
0 0
Ill u..
.:.:<{
(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
F.
(/)
:::>
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
G.
::
-�
><
0 '0 ..
Ill
0::
°'
�
; (U
.c
f
� c. E
0
(.)a..�
□
J
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
A.
D.
C.
B.
F.
E.
Number of Portions
Portion
Size
(Include
Units)
Food Item
HOT CEREALS
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
·- "C
><
Left Over for
Later Use
Wasted
cup
Grits
cup
I
Oatmeal
cup
5'
'-I
DJ u.
Manufacturer/Brand Name and
Product Code
(If Applicable)
-"
..c �
D
D
D
D
D Quick
□ Reg
D
D
D Instant
D Quick
D Reg
D
D
D Instant
D Quick
efReg
D
Yi
D
D
CJ
�Vrltr �� .j, (oo o'
D Fruit
D Cheese
'\!Icing/glaze
D No Icing/glaze
I 0\
0
I
San.,
0
D Butter
Specify type:
Lae :¼tL.f"fll
Specify type: /I}(}/
W· �L11e v.;e rVfl\
D No Icing
D Icing
Specify type:
D Margarine
D Butter
D Low-fat
D Plain
D Other:
4
D
D
D
D
D
D
D
D
D
D
D
D
D
D
Specify type:
oz.
D
D
D Margarine
20
1001- !t:tho!e. whtttA-
D Fruit
D Chocolate chip
D
D
D
D
0
ua...::
D Instant
Specify type:
(1)
(1)
0:::
��m
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 l,a/ I
.e"
(1)
><
D
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
A.
B.
D.
C.
F.
E.
Number of Portions
Portion
Size
(Include
Units)
Food Item
Waffle sticks
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
� 'O
X 0
0 0
Left Over for
Later Use
Wasted
Manufacturer/Brand Name and
Product Code
(If Applicable)
al u.
..,. <{
Food Description
□ Plain □ Fruit □ Chocolate chip
□ Other:
oz.
Weight of each stick:
ea.
c
u
Cl) (/)
<3:::i
G.
:t:
><
0
ill al &
�
u
:;
□
0
□
□
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 meaUmeat alternate or combination item. For example, sausage with
biscuit, or yogurt with cereal).
Bacon
Eggs
cup
Ham
oz.
Peanut butter
Sausage
□ Turkey
□ Pork
□ Scrambled D Hard boiled
□ Fried
□ Turkey
□ Pork
sl
w I l?l\vW1
Yogurt
COMBINATION ITEMS
Breakfast burrito
J
oz
(t;
0
D
0
�educed-fat
□ Beef or pork □ Chicken or turkey
D Reg □ Low-fat □ Fat-free □ Light
oz.
Specify flavors:
D Eggs D Cheese D Beans
Other:
oz.
1
.-imlWl'Orr
'J 0
'),0
0
0
0
S<1� l-O
.Jki-hZ'f
0Cheese
□ Potato D
lefsausage □ Ham
□ Other:
D Bacon
Specify bread type: WhJ2.M- 8Yl(I\ \1! YI W1vffi11.
D Sausage
D Ham
Grilled cheese
□
D
D
D
D
D
D
D Other:
D Bacon
Specify bread type:
1
sandwich
ea.
Weight of each stick:
D Reduced-fat
sandwich
5
D
D
D
□
-
French toast
French toast sticks
0
(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).
D Cheese
Ega sandwich
□
0
oz.
j.� OZEaa sandwich
(p
0
0
D
D
D
D
□
oz.
(ti
c. E
1�o
u Q.�
□
□
-�
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
A.
D.
C.
B.
F.
E.
Number of Portions
Food Item
Pancake on a stick
Pizza
Portion
Size
(Include
Units)
2- .$' oz.
Total
Prepared
ID
Reimbursable
Served
_q
Served A La
Carte or to
Adults/Others
I
Left Over for
Later Use
0
Wasted
()
Manufacturer/Brand Name and
Product Code
(If Applicable)
� f".11�" � 7o roo r
Food Description
TiBeef or pork □ Chicken or turkey
□ Reduced-fat
Specify toppings:
oz.
·-,:,
>< 0
0 0
ID 11.
.,. <(
CJ 0
Q) (/)
(3::>
□
□
□
□
D
□
G.
Q)
.!:!
CJ
><
0 ,:, Q)
ID a, 0::
� ti; ra
CJ c.
E
��o
(.) CL J::
□
D
D
D
D
CONDIMENTS
Self-serve condiments or fixins'
bar
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
1 serving
D
Butter
□ Reg
Cream cheese
D Red. fat
□ Reg □ Red.fat
Gravv
I oz.
Jellv
/o
5'
D
�
D
□ Sugar-free
□ Fat-free
D
□
D
D
Margarine
v' l�ytCJ,\�
D
□
Ketchup
svrup
D Low-fat
□ Fat-free
D
Honey
Salsa
D Light
□ Low sodium
2-oz,..
{D
°I
I
0
0
6
RlSugar-free
D
D
□
D
□
D
D
D
□
D
D
D
D
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
D.
C.
B.
A.
E.
:'!::�
>< 0
0 0
Ill u.
.,,,_ <(
Number of Portions
Food Item
OTHER MENU ITEMS
6;t1lb--Vl - G!o
btea. ��.s +-
Portion
Size
(Include
Units)
I
�
Total
Prepared
Lf
Reimbursable
Served
'-f
Served A La
Carte or to
Adults/Others
0
Left Over for
Later Use
0
Wasted
0
Manufacturer/Brand Name and
Product Code
(If Applicable)
F.
oc
Food Description
Q> Cl)
<3::::,
□
□
D
D
D
□
□
□
□
□
7
G.
.e
Q>
::
0
><
0 "C Q>
Ill 0:::
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(_) Q..::
□
□
□
□
□
□
□
D
D
□
□
D
D
D
D
□
D
D
D
D
D
D
D
D
D
□
D
D
D
0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Reimbursable Meal Counts
How many reimbursable lunches did you plan to serve at your school this
day?
How many reimbursable lun_ches did you serve at your school this day?
SCHOOL NUTRITION AND MEAL COST STUDY-II
IS"V
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
I 2- <;""
NOTE: For instructions on completing this form, please refer lo Ins/ructions for the Menu Survey.
Date:. ___,_l
Portion
Size
(Include
Units)
Food Item
MILK
i
White, fat-free/skim
3
White, 1%
fl oz.
fl oz.
White, 2%
fl oz.
White, whole
fl oz.
8
Chocolate, fat-free/skim
fl oz.
Chocolate, 1%
fl oz.
Chocolate, 2%
fl oz.
Other flavor
Specify: . ,(+rttW\.-u> (YIA
Other flavor
Specify:
Other flavor
Specify:
_,
�
fl oz.
fl oz.
fl oz.
Day:
Ki'Mon
□ Tue
• School Nutrition &
Meal Cost Study -11
□ Thu
□ Wed
:t:
><
0
al
Number of Portions
Total
Prepared
$1)
so
Reimbursable
Served
zo
Served A La
Carte or to
Adults/others
s-
Left Over for
Later Use
Wasted
2�
2Jo
0
D
ii-
i
7c;-
Lf 3
7
2,r;-
0
7r;-
�o
i
21
0
Manufacturer/Brand Name and Product
Code
(If Aoo/icable)
□ Fri
F.
E.
D.
C.
B.
A.
-+-(-=-CR----1-/--'£...2{}-=----
D
"C
0
0
LL
-"' < 0
0 0
al IL
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Manufacturer/
Brand Name and Product Code
13::,
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(If applicable)
Ingredient Description
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□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Recipe Form (Basic)
D
• School Nulrlllon &
Meal Cost Study- n
NOTE: For ins/ructions on completing this form, please refer to the Instructions for the Menu Survey.
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• School Nutrition &
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D
• School Nulridon &
Meal Cost Study- II
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NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
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D
• School Nutrlllon •
Meal Cost Study - II
NOTE: For instructions on completing this form, please refer lo the Instructions for the Menu Survey.
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Expiration Date: XX/XX/XXXX
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D
• School Nutrition &
Meal Cost Study• II
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
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D
• School Nwitlon &
Meal Cost Study -11
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
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D
• School Nutrition &
Meal Cost Study- II
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu SuNey.
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0MB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
D
• School Nutrition &
Meal Cost Study -11
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
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Expiration Date: XX/XX/XXXX
D
• School Nutrition &
Meal Cost Study -11
SCHOOL NUTRITION AND MEAL COST STUDY-II
NSLP Afterschool Snack Form (Basic}
For instructions on completing this booklet of forms, please refer to the Instructions for the Menu Survey.
School Name:
1.
_J-=--o_h---'-n---'---_.S_m_(_-f1_fl _m_r_J_d_Ce_S_vvt_o_o_(_
Please indicate the days that afterschool snacks were offered during
t_he target week:
!Z5
ief
ii"
Monday
Tuesday
Wednesday
ef Thursday
□
Friday
0MB Control Num ber: 0584-XXXX
Expiration Date: XX/XX/XXXX
D
.. School Nulrilion &
Meal Cost Stud-y - II
A La Carte Foods Checklist (Basic)
SCHOOL NAME:
----------------------------
COMPLETE ON: [insert sticker with day of week]
DATE COMPLETED:
I_Q_l_l_i t l_Q_I_JQ_I / I 2.,,I_QI 2..-I_QI
Month
Day
Year
Note: Please refer to the Instructions for the Menu Survey for instructions on completing this form.
MENU SURVEY SCREENER – BASIC (GROUP 2)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Menu Survey Screener Questions (Basic)
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
2.
Does your school provide reimbursable snacks or suppers for one or more afterschool
programs (either at this school or another location)?
2a.
School provides afterschool snacks through the National School Lunch Program (NSLP).
1
0
2b.
0
No
□
□
Yes
No
School provides afterschool suppers through the CACFP.
1
0
3.
Yes
School provides afterschool snacks through the Child and Adult Care Food Program
(CACFP).
1
2c.
□
□
□
□
Yes
No
Does your school’s food service department sell any foods or beverages outside of
reimbursable meals? This may include foods or beverages that are offered as part of
reimbursable meals but also sold on an a la carte basis, as well as foods and beverages that
are sold only outside of reimbursable meals.
1
0
□
□
Yes
No
[If no, skip to Q5]
[If Q3 = Yes]:
4.
In what locations does your school’s food service department sell foods or beverages
outside of reimbursable meals?
MARK ALL THAT APPLY
1
2
3
4
5
6
7
□
□
□
□
□
□
□
[If Q1 = Yes] A la carte serving lines at breakfast
A la carte serving lines at lunch
Snack bars
Vending machines
Food carts
School stores
Other, Specify: ______________________________
1
MENU SURVEY SCREENER QUESTIONS (BASIC)
5.
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 Q5 = No]
5a. 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.]
2
DAILY MEAL COUNTS FORM (GROUP 2)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-xxxx
Expiration Date: xx/xx/xxxx
Daily Meal Counts Form (Basic)
School Name:
Date:
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
→ 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
→ Reason:
________________________________
Tuesday
→ Reason:
________________________________
Wednesday
→ Reason:
________________________________
Thursday
→ Reason:
________________________________
Friday
→ Reason:
________________________________
1
This page has been left blank for double-sided copying.
REIMBURSABLE FOODS FORM:
BREAKFAST (GROUP 2)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Reimbursable Meal Counts
SCHOOL NUTRITION AND MEAL COST STUDY-II
Reimbursable Foods Form: Breakfast (Basic)
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?
B.
C.
Mon
Day:
Tue
Wed
Thu
D.
E.
F.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Fri
G.
Check Box if
Prepared
from a Recipe
A.
Date:______________________________
Check Box if
USDA Food
School Name:__________________________________________
NOTE: For instructions on completing this form, please refer to Instructions for the Menu Survey.
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.
Other flavor
Specify:
____________________
fl oz.
Other flavor
Specify:
____________________
fl oz.
Other flavor
Specify:
____________________
fl oz.
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
fl oz.
fl oz.
fl oz.
1
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
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 a RECIPE FORM.)
Apple, fresh
Applesauce, canned
Apricots, canned
cup
Sweetened
Unsweetened
Heavy syrup
Light syrup
Extra light syrup Juice Water
cup
Sweetened
cup
Heavy syrup
Fruit cocktail, canned
cup
Grapes, fresh
cup
Unsweetened
Light syrup
Extra light syrup Juice Water
Heavy syrup
Light syrup
Extra light syrup Juice Water
cup
Heavy syrup
Light syrup
Extra light syrup Juice Water
cup
Pears, fresh
Heavy syrup
Pears, canned
Orange, fresh
Peaches, canned
Kiwi, raw
Mandarin oranges, canned
Banana, fresh
Blueberries, frozen
cup
Heavy syrup
Pineapple, canned
cup
Raisins
oz.
Light syrup
Extra light syrup Juice Water
Light syrup
Extra light syrup Juice Water
2
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
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.
Calcium added
Grape juice
fl oz.
Calcium added
Orange juice
fl oz.
Calcium added
Fruit juice blend
fl oz.
Calcium added
fl oz.
BREADS AND GRAINS (Note: In Column A, indicated 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.
Cheerios, Fruity
oz.
Cheerios, Honey Nut
oz.
Cinnamon Toast Crunch
oz.
Cocoa Krispies
oz.
Cocoa Puffs
oz.
Froot Loops
oz.
Frosted Flakes
oz.
Frosted Mini Wheats
oz.
Golden Grahams
oz.
Granola
oz.
Kix
oz.
Lucky Charms
oz.
Marshmallow Mateys
oz.
Raisin Bran
oz.
Rice Chex
oz.
Rice Krispies
oz.
Trix
oz.
Reg Low-fat
3
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
C.
D.
E.
F.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
G.
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
HOT CEREALS (Note: If prepared with fat and/or milk, complete a 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 (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).
Specify type: ___________________
Bagel
oz.
Biscuit
oz.
Danish or turnover
oz.
Fruit
Cheese
Doughnut
oz.
Icing/glaze
No Icing/glaze
English muffin, plain
oz.
English muffin, buttered
oz.
Margarine
Granola/cereal bar
oz.
Specify type: ___________________
Muffin
oz.
Specify type: ___________________
Pancake
oz.
Roll, cinnamon
oz.
Icing
Toast, plain
oz.
Specify type: ___________________
Specify type: ___________________
Toast, buttered
oz.
Toaster pastry
oz.
Butter
No Icing
Margarine
4
Fruit
Chocolate chip
Other:____________
oz.
Butter
Low-fat
Plain
Waffles
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Plain Fruit Chocolate chip
Other:____________
Waffle sticks
F.
G.
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).
Bacon
Pork
sl
Turkey
Eggs
cup
Scrambled Hard boiled
Fried
Ham
oz.
Pork
Peanut butter
oz.
Reduced-fat
Sausage
oz.
Beef or pork Chicken or turkey
Turkey
Reg Low-fat Fat-free Light
Yogurt
Specify flavors: _________________
oz.
COMBINATION ITEMS (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).
Breakfast burrito
Eggs Cheese Beans Potato
Other:_______________
oz.
Cheese
Egg sandwich
Cheese
Egg sandwich
Sausage
Sausage
French toast
French toast sticks
Grilled cheese
ea.
1
sandwich
5
Ham
Bacon
Other:____________
Specify bread type: ______________
1
sandwich
Ham
Bacon
Other:____________
Specify bread type: ______________
1
sandwich
Weight of each stick:_________oz.
Reduced-fat
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
C.
D.
E.
F.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
G.
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
Pancake on a stick
oz.
Beef or pork Chicken or turkey
Pizza
oz.
Reduced-fat
Specify toppings: _______________
CONDIMENTS
Self-serve condiments or fixins’
bar
Please list all ingredients on a SELF-SERVE/ MADE-TO-ORDER BAR FORM
1 serving
Butter
Reg Red. fat
Light
Fat-free
Reg Red. fat
Low-fat Fat-free
Cream cheese
Gravy
Honey
Sugar-free
Jelly
Ketchup
Margarine
Salsa
Syrup
6
Low sodium
Sugar-free
REIMBURSABLE FOODS FORM: BREAKFAST (BASIC)
C.
D.
E.
Manufacturer/Brand Name and
Product Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
F.
G.
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
OTHER MENU ITEMS
7
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REIMBURSABLE FOODS FORM:
LUNCH (GROUP 2)
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OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
SCHOOL NUTRITION AND MEAL COST STUDY-II
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
Reimbursable Meal Counts
How many reimbursable lunches did you plan to 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
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Fri
F.
G.
Check Box if
Prepared
from a Recipe
School Name:___________________________________________ Date:______________________________
Check Box if
USDA Food
How many reimbursable lunches did you serve at your school this day?
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.
Other flavor
Specify: _____________________
fl oz.
Other flavor
Specify:_____________________
fl oz.
Other flavor
Specify: _____________________
fl oz.
fl oz.
fl oz.
fl oz.
1
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
Fat-free/skim
1%
2%
B.
C.
D.
E.
F.
G.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Check Box if
Prepared
from a Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
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, list as separate item and complete a RECIPE FORM.)
Apple, fresh
Applesauce, canned
Apricots, canned
cup
Sweetened
Unsweetened
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Banana, fresh
cup
Sweetened
Unsweetened
Fruit cocktail, canned
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Grapes, fresh
cup
Blueberries, frozen
Kiwi, raw
Mandarin oranges, canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
cup
Orange, fresh
Peaches, canned
Heavy syrup
Light syrup
Extra light syrup Juice
Water
cup
Pears, fresh
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Pineapple, canned
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Raisins
oz.
Pears, canned
2
B.
D.
E.
F.
G.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Check Box if
Prepared
from a Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
C.
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
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
Grape juice
fl oz.
Calcium added
Orange juice
fl oz.
Calcium added
Fruit juice blend
fl oz.
Calcium added
Frozen juice cup/bar
fl oz.
Specify flavor: ______________
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.)
cup
Vegetarian
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_______________________
Broccoli, cooked
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
________________________
Broccoli, raw
cup
Baked beans
Beans, green
Carrots, cooked
cup
Carrots, raw
cup
Cauliflower, raw
cup
Celery, raw
cup
Corn, kernels
cup
Cucumber, raw
cup
French fries
cup
With pork
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
If offered, list dip as separate item(s) or complete a RECIPE FORM
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
3
Deep-fried
B.
C.
D.
E.
F.
G.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Check Box if
Prepared
from a Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
Number of Portions
Food Item
Lettuce and tomato
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
cup
cup
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Peas, green
cup
Fresh
Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Potatoes, whipped or mashed
cup
From fresh
Refried beans
cup
From dry Canned
Low sodium
Fat added, specify type:
_________________________
Red peppers, raw
cup
If offered, list dip as separate item(s) or complete a RECIPE FORM
Green peppers, raw
cup
If offered, list dip as separate item(s) or complete a RECIPE FORM
Mixed vegetables
Sweet potatoes
cup
Fresh Frozen
Canned Low sodium
Fat added, specify type:
_________________________
Sweet potato fries or tots
cup
Oven-baked
Side salad bar
(non-entrée or small portion)
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Salad, tossed
cup
Tater tots or shapes
cup
Tomato, raw
cup
Deep-fried
List dressing and any bread/grain items offered with the tossed salad as separate
item(s)
Oven-baked
Deep-fried
If offered, list dip as separate item(s) or complete a RECIPE FORM
4
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
C.
D.
E.
F.
G.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
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 & 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
1 sandwich
1 sandwich
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
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.)
Breaded
Beef or pork
Chicken or turkey
Beef Pork
Chicken or turkey
5
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
C.
D.
E.
F.
G.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
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
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
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.)
SELF-SERVE/MADE-TO-ORDER ENTRÉE BARS
Entrée salad bar
1 serving
Potato bar
1 serving
Nacho/taco bar
1 serving
Sandwich/deli bar
1 serving
Pasta/Italian bar
1 serving
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
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
6
B.
C.
D.
E.
F.
G.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Check Box if
Prepared
from a Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
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)
____________________
cup
From dry
Canned
Low sodium Fat added, specify
type: _______________
Burrito
oz.
Bean
Chicken
Cheese (string cheese or cubes)
oz.
Reduced-fat
oz.
Reduced-fat
Specify fillings:
________________________
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
Beef
Cheese
Chicken piece(s)
(Specify part)__________________
Oven-baked
Deep-fried
Breaded
Oven-baked
With skin
Deep-fried
oz.
Beef or pork
Chicken or turkey
ea.
Meatless Beef or pork
Chicken or turkey
Weight of each egg
roll:__________oz.
Fish sticks or nuggets
ea.
Oven-baked Deep-fried
Breaded
Weight of each
nugget/stick:__________oz.
Macaroni and cheese
cup
Nachos
oz.
Peanut butter
oz.
Corndog
Egg rolls
Pizza, cheese
oz.
Pizza, pepperoni
oz.
Reduced-fat
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
7
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
C.
D.
E.
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Pizza, sausage
oz.
Pizza, vegetarian
oz.
Food Description
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
Reduced-fat
Thick crust (deep-dish, bagel, French
bread)
Specify toppings:____________
Pizza pocket
oz.
Reduced-fat
Specify filling:_______________
Stir fry with rice or noodles
cup
Spaghetti with sauce
Wasted
Manufacturer/Brand Name and Product
Code
(If Applicable)
Meat sauce
Marinara sauce
cup
Hard shell Soft tortilla
Bean
Beef
Chicken
Cheese
Specify type: Regular Greek (high
protein)
Specify fat: Whole Low-fat
Taco
F.
G.
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
Fat-free Light
Yogurt
Specify flavors: _________________
oz.
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.
Corn/tortilla chips
oz.
Specify type:_______________
Crackers
ea.
Croutons
oz.
Rice
cup
White
Roll
oz.
Specify type:_______________
Pasta
cup
Brown
Wild
8
B.
C.
E.
F.
G.
Food Description
Check Box if
Prepared
from a Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
D.
Number of Portions
Food Item
Pretzels
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Manufacturer/Brand Name and Product
Code
(If Applicable)
Soft
Salted
oz.
Hard
Unsalted
DESSERTS, DRINKS, AND SNACKS OFFERED AS PART OF A REIMBURSABLE MEAL
Brownie
Icing
Cake
Specify type: _______________
Specify type: _______________
Specify type: _______________
fl oz.
Specify type: _______________
Fruit turnover
oz.
Specify type: _______________
Gelatin
cup
With fruit
With whipped topping
Potato chips
oz.
Reduced-fat
Cookie
oz.
Fruit crisp or cobbler
Fruit drink (not 100% juice)
Baked
SALAD DRESSINGS
Caesar dressing
Reg Light Red. calorie
Fat-free
French dressing
Reg Light Red. calorie
Fat-free
Honey mustard 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
9
B.
C.
D.
E.
F.
G.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Check Box if
Prepared
from a Recipe
A.
Check Box if
USDA Food
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
CONDIMENTS
Self-serve condiments or fixins’ bar
Please list all ingredients on a SELF-SERVE/MADE-TO-ORDER BAR FORM
1 serving
Barbeque sauce
Butter
Cream cheese
Reg Red. fat Low-fat
Fat-free
Gravy
Reg Red. fat Low-fat
Fat-free
Honey
Hot sauce
Jalapeno peppers
Sugar-free
Jelly
Ketchup
Margarine
Reg Red. fat Low-fat
Fat-free
Mayonnaise
Mustard
Pickles, slices
Reg Red. fat Low-fat
Fat-free
Ranch dip
Relish
Salsa
Low sodium
Sour cream
Reg Red. fat Low-fat
Fat-free
Syrup
Sugar-free
Tartar sauce
Reg Red. fat Low-fat
Fat-free
10
REIMBURSABLE FOODS FORM: LUNCH (BASIC)
C.
D.
E.
F.
G.
Manufacturer/Brand Name and Product
Code
(If Applicable)
Food Description
Number of Portions
Food Item
Portion
Size
(Include
Units)
Total
Prepared
Reimbursable
Served
Served A La
Carte or to
Adults/Others
Left Over for
Later Use
Wasted
Check Box if
Prepared
from a Recipe
B.
Check Box if
USDA Food
A.
OTHER MENU ITEMS
11
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RECIPE FORM (GROUP 2)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Recipe Form (Basic)
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
1
Mon
6
All
2
2
Tue
Lunch
3
Wed
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)
Ingredient Description
1
E.
F.
Check Box if
Prepared from
a Recipe
Day:
Recipe/Food Name:
Check Box if
USDA Food
School Name:
1 Breakfast
Meal:
This page has been left blank for double-sided copying.
SELF-SERVE/MADE-TO-ORDER BAR FORM (GROUP 2)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Self-Serve/Made-to-Order Bar Form (Basic)
NOTE: For instructions on completing this form, please refer to the Instructions for the Menu Survey.
1
Breakfast
A.
Food Name
2
Lunch
Day:
1
All
2
Mon
3
Tue
4
Wed
B.
C.
D.
Portion Size,
If
Pre-portioned
(Include units)
Manufacturer/
Brand Name and
Product Code (if
applicable)
Food Description
1
5
Thu
E.
6
Fri
F.
Check Box if
Prepared from
a Recipe
Meal:
Name of Bar:
Check Box if
USDA Food
School Name: ________________________________
This page has been left blank for double-sided copying.
NSLP AFTERSCHOOL SNACK FORM (GROUP 2)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
SCHOOL NUTRITION AND MEAL COST STUDY-II
NSLP Afterschool Snack Form (Basic)
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 afterschool snacks were offered during
the target week:
Monday
Tuesday
Wednesday
Thursday
Friday
This page has been left blank for double-sided copying.
NSLP Afterschool Snack Form (Basic)
Day:
Mon
Tue
Wed
Thu
A.
Fri
Number of Reimbursable Snacks Served:
B.
C.
D.
Number of Reimbursable
Portions
Food Item
Portion Size
(Incl. Units)
Prepared/
Available
Served
Food Description
Milk
White
fl oz.
Fat-free/skim
1%
2%
Chocolate
fl oz.
Fat-free/skim
1%
2%
Other flavor, Specify: ____________________
fl oz.
Fat-free/skim
1%
2%
fl oz.
Fat-free/skim
1%
2%
cup
Sweetened
Unsweetened
cup
Heavy syrup
Light syrup
Extra light syrup Juice
Water
Other flavor, Specify: ____________________
Fruit
Apple, fresh
Applesauce, canned
Banana, fresh
Fruit cocktail, canned
Orange, fresh
Raisins
oz.
Juices
Apple juice
fl oz.
Calcium added
Orange juice
fl oz.
Calcium added
Grape juice
fl oz.
Calcium added
Vegetables (if offered with a dip, list the dip as a separate item in the condiments section)
Carrots, raw
cup
Celery, raw
cup
Combination Items and Entrées
Peanut butter & jelly sandwich
Pizza
Sandwich
Whole grain-rich
1 sandwich
oz.
Whole grain-rich Reduced-fat
Specify toppings:_____________________
1 sandwich
Whole grain-rich
Specify ingredients:___________________
1
NSLP AFTERSCHOOL SNACK FORM (BASIC)
A.
B.
C.
D.
Number of Reimbursable
Portions
Food Item
Portion Size
(Incl. Units)
Prepared/
Available
Served
Food Description
Meat and Meat Alternates
Cheese
oz.
Reduced-fat
Specify type:________________________
Trail mix
oz.
Specify ingredients:___________________
oz.
Regular Low-fat Fat-free
Light
Specify flavor(s):_____________________
Bagel
oz.
Whole grain-rich
Specify type:_______________________
Cereal
oz.
Whole grain-rich
Specify type:_______________________
Cookie
oz.
Whole grain-rich
Specify type:_______________________
Corn/tortilla chips
oz.
Whole grain-rich
Specify type:_______________________
Crackers
ea.
Whole grain-rich
Specify type:_______________________
Granola bar
oz.
Whole grain-rich
Specify type:_______________________
oz.
Whole grain-rich
Soft
Hard
Salted
Unsalted
Yogurt
Breads and Grains
Pretzels
Whole grain-rich
Whole grain-rich
Whole grain-rich
Desserts and Other Items
Fruit snacks/fruit leather
Fruit drink (less than 100% juice)
fl oz.
Specify flavor(s):____________________
Pudding
Condiments
Ranch dip
Reg Light Red. calorie
Fat-free
Cream cheese
Reg Red. fat Light Fat-free
Ketchup
2
MENU SURVEY ENHANCEMENTS ADMINISTERED THROUGH THE
ELECTRONIC MENU SURVEY (EMS) (GROUP 2)
This page has been left blank for double-sided copying.
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
Questions Related to Offering Different Foods
and/or Portion Sizes to Students in
Different Grade Groups
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 Q5 and Q5a), the 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 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 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
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)
1
f.
Bread and grain items offered separately (such as crackers,
croutons, rolls, tortilla chips)
1
g. Desserts, drinks, and snack items (such as cookies, fruit drinks, Jello)
1
h. Condiments and salad dressings
1
2
□
□
□
□
□
□
□
□
NO
0
0
0
0
0
0
0
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.
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
1
b. 100% juice
c.
1
Fruits and vegetables (excluding juice)
1
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
1
1
1
□
□
□
□
□
□
NO
0
0
0
0
0
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 Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
EMS Foods Paired/Offered Together Module
and Food Bar Questions
Note: The 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
A LA CARTE FOODS CHECKLIST (GROUP 2)
This page has been left blank for double-sided copying.
1
OMB Control Number: 0584-XXXX
Expiration Date: XX/XX/XXXX
A La Carte Foods Checklist (Basic)
SCHOOL NAME:
COMPLETE ON: [insert sticker with day of week]
DATE COMPLETED:
|
|
|/|
Month
|
Day
|/|
|
|
|
|
Year
Note: Please refer to the Instructions for the Menu Survey for instructions on completing this form.
1
A LA CARTE FOODS CHECKLIST (BASIC)
SCHOOL NUTRITION AND MEAL COST STUDY-II
A La Carte Foods Checklist (Basic)
Food Item
A.
Breakfast
Milk
□
2 □
3 □
4 □
5 □
6 □
7 □
1.
Whole white milk
2.
Reduced fat (2%) white milk
3.
Low-fat (1% or 0.5%) white milk
4.
Fat-free/skim white milk
5.
Reduced fat (2%) flavored milk
6.
Low-fat (1% or 0.5%) flavored milk
7.
Fat-free/skim flavored milk
8.
Other milk beverages, including non-dairy milks (Specify)
1
□
8.2 □
8.3 □
8.4 □
8.5 □
a.
8.1
b.
c.
d.
e.
B.
□
2 □
3 □
4 □
5 □
6 □
7 □
1
□
8.2 □
8.3 □
8.4 □
8.5 □
8.1
100% Juice and Water
1.
C.
Lunch
□
2 □
Juice (100% fruit or vegetable juice)
1
2. Bottled water (plain, flavored, or sparkling)
Beverages Other than Milk, 100% Juice, or Water
1.
Diet carbonated soft drink (diet soda/pop)
2.
Regular carbonated soft drink (regular soda/pop)
□
2 □
3.
Juice drinks and other sweetened drinks (such as cranberry drink, Hi-C,
lemonade, fruit punch, iced tea)
3
1
4.
Sports drinks (such as Gatorade or PowerAde)
5.
Energy drinks (such as Red Bull or Monster Energy)
6.
Hot or cold chocolate drinks (such as Yoo-hoo; NOT chocolate milk)
7.
Hot or cold coffee or tea
8.
Other beverages (Specify)
□
4 □
5 □
6 □
7 □
□
8.2 □
8.3 □
8.4 □
8.5 □
a.
8.1
b.
c.
d.
e.
1
□
2 □
1
□
2 □
1
□
4 □
5 □
6 □
7 □
3
□
8.2 □
8.3 □
8.4 □
8.5 □
8.1
A LA CARTE FOODS CHECKLIST (BASIC)
Food Item
D.
E.
Breakfast
Lunch
Fruit
1.
Dried fruit (such as raisins or apricots)
2.
Canned or frozen fruit
□
2 □
3 □
1
3. Fresh fruit
Vegetables
□
2 □
3 □
1
COOKED
1. Baked French fries (including tater tots and sweet potato fries)
2. Deep-fried French fries (including tater tots)
3. Potatoes or sweet potatoes (other than French fries/tater tots/sweet potato fries)
4. Corn
5. Carrots
6. Broccoli
7. Peas
8. Green beans
9. Mixed vegetables
10. Vegetable soup
11. Beans/legumes (such as baked beans, black beans, or pinto beans)
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
1
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
1
12. Other cooked vegetables (Specify)
□
12.2 □
12.3 □
12.4 □
12.5 □
a.
12.1
b.
c.
d.
e.
□
12.2 □
12.3 □
12.4 □
12.5 □
12.1
RAW (NOT COOKED)
13. Carrot sticks
□
14 □
15 □
16 □
17 □
18 □
13
14. Celery
15. Cucumbers
16. Salad bars
17. Tossed salads (side)
18. Prepared vegetable salads (such as potato salad, coleslaw, or three bean salad)
□
14 □
15 □
16 □
17 □
18 □
13
19. Other raw vegetables (Specify)
□
20.2 □
21.3 □
a.
19.1
b.
c.
2
□
20.2 □
21.3 □
19.1
A LA CARTE FOODS CHECKLIST (BASIC)
Food Item
Breakfast
□
23.5 □
d.
F.
22.4
e.
Breads and Grains
1.
Whole grain-rich breads, rolls, bagels, or tortillas
2.
Regular (not whole grain-rich) bread, rolls, bagels, or tortillas
3.
Other bread items (such as breadsticks, biscuits, croissants, or hot pretzels)
4.
Low-fat muffins
5.
Regular muffins (not lower in fat)
6.
Ready-to-eat breakfast cereal
7.
Pancakes, waffles, or French toast
8.
Rice, pasta, or cooked cereal
9.
Other bread/grains (Specify)
□
9.2 □
9.3 □
9.4 □
9.5 □
a.
b.
c.
d.
e.
G.
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
1
Lunch
□
23.5 □
22.4
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
1
□
9.2 □
9.3 □
9.4 □
9.5 □
9.1
9.1
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 □
13 □
14 □
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 □
13 □
14 □
Meats or Meat Alternates
1. Breaded chicken/turkey (nuggets, patties, strips, parts)
1
2. Not breaded chicken/turkey (nuggets, patties, strips, parts)
3. Breaded beef/pork (nuggets, patties, strips)
4. Not breaded beef/pork (nuggets, patties, strips)
5. Sausage or bacon
6. Breaded fish (nuggets, patties, strips/sticks)
7. Not breaded fish (nuggets, patties, strips/sticks, fillets)
8. Eggs
9. Cheese (including string cheese)
10. Fried or baked cheese or pizza sticks (for example, Bosco sticks)
11. Chili
12. Yogurt
13. Peanut butter or other nut or seed butter
14. Nuts and/or seeds (such as almonds, peanuts, sunflower seeds, or trail mix)
3
1
A LA CARTE FOODS CHECKLIST (BASIC)
Food Item
Breakfast
Lunch
15. Other meats/meat alternates (Specify)
□
15.2 □
15.3 □
15.4 □
15.5 □
a.
15.1
b.
c.
d.
e.
H.
□
15.2 □
15.3 □
15.4 □
15.5 □
15.1
Entrees
SANDWICHES
1. Cheeseburger or hamburger
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
1
2. Hot dog or corn dog
3. Barbecue sandwich (including sloppy joes)
4. Peanut butter or other nut or seed butter sandwich (including with jelly)
5. Cheese sandwich
6. Veggie burger
7. Chicken, egg, or tuna salad sandwich
8. Sandwich with breaded meat, poultry or fish
9. Sandwich with cold cuts (salami, bologna, or pepperoni)
10. Sandwich with plain (not breaded) meat, poultry or fish
11. Breakfast sandwich or breakfast burrito
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
1
12. Other sandwiches (Specify)
□
12.2 □
12.3 □
12.4 □
12.5 □
a.
12.1
b.
c.
d.
e.
□
12.2 □
12.3 □
12.4 □
12.5 □
12.1
OTHER ENTREES
13. Pizza without meat
□
14 □
15 □
16 □
17 □
18 □
19 □
20 □
13
14. Pizza with meat
15. Calzone or Hot Pocket
16. Burritos
17. Other Mexican foods (such as tacos, nachos, or quesadillas)
18. Chinese food
19. Lasagna
20. Spaghetti
4
□
14 □
15 □
16 □
17 □
18 □
19 □
20 □
13
A LA CARTE FOODS CHECKLIST (BASIC)
Food Item
Breakfast
21. Macaroni and cheese
22. Entrée salad (such as chef’s, cobb, taco, or chicken Caesar)
23
□
22 □
23 □
21
Soup with meat or beans (such as chicken, clam chowder, or minestrone)
Lunch
□
22 □
23 □
21
24. Other entrees (Specify)
□
24.2 □
24.3 □
24.4 □
24.5 □
a.
24.1
b.
c.
d.
e.
I.
□
24.2 □
24.3 □
24.4 □
24.5 □
24.1
Baked Goods and Desserts
1. Low-fat/reduced-fat cakes, cupcakes, or brownies
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
1
2. Regular cakes, cupcakes, or brownies (not lower in fat)
3. Low-fat pies, turnovers, or toaster pastries
4. Regular pies, turnovers, or toaster pastries (not lower in fat)
5. Low-fat doughnuts or cinnamon rolls
6. Regular doughnuts or cinnamon rolls (not lower in fat)
7. Low-fat cookies
8. Regular cookies (not lower in fat)
9. Fruit crisp or cobbler
□
2 □
3 □
4 □
5 □
6 □
7 □
8 □
9 □
1
10. Other baked goods/desserts (Specify)
□
10.2 □
10.3 □
10.4 □
10.5 □
a.
10.1
b.
c.
d.
e.
J.
□
10.2 □
10.3 □
10.4 □
10.5 □
10.1
Frozen and Dairy Desserts
1.
Frozen fruit bars or popsicles
2.
Milkshakes, smoothies, or yogurt drinks
3.
Low-fat/reduced-fat ice cream, novelties, frozen yogurt, or sherbet
4.
Regular ice cream, novelties, frozen yogurt, or sherbet
5.
Pudding
□
2 □
3 □
4 □
5 □
1
5
□
2 □
3 □
4 □
5 □
1
A LA CARTE FOODS CHECKLIST (BASIC)
Food Item
6.
Breakfast
Other frozen/dairy dessert (Specify)
□
6.2 □
6.3 □
6.4 □
6.5 □
a.
6.1
b.
c.
d.
K.
Lunch
e.
Snacks
1. Low-fat/reduced-fat/baked chips (such as corn, potato, puffed cheese, tortilla, or
snack mixes)
2. Regular chips (not lower in fat; such as corn, potato, puffed cheese, tortilla, or
snack mixes)
3. Hard pretzels
4. Popcorn
5. Cracker sandwiches with cheese or peanut butter
6. Other types of crackers (including animal crackers)
7. Low-fat/reduced-fat granola bars, cereal bars, or energy bars
8. Regular granola bars, cereal bars, or energy bars (not lower in fat)
9. Crispy rice bars or treats
10. Candy or gum
11. Fruit snacks (such as Fruit Roll-Ups or fruit leather)
12. Meat snacks (such as jerky or pork rinds)
1
□
□
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 □
2
□
6.2 □
6.3 □
6.4 □
6.5 □
6.1
1
□
□
3 □
4 □
5 □
6 □
7 □
8 □
9 □
10 □
11 □
12 □
2
13. Other snacks (Specify)
□
13.2 □
13.3 □
13.4 □
13.5 □
a.
13.1
b.
b.
b.
L.
b.
Other A La Carte Items (Specify)
□
1.2 □
1.3 □
1.4 □
1.5 □
a.
1.1
b.
c.
d.
e.
6
□
13.2 □
13.3 □
13.4 □
13.5 □
13.1
□
1.2 □
1.3 □
1.4 □
1.5 □
1.1
| File Type | application/pdf |
| Subject | Instructions |
| Author | Denise Mercury, Liz Condon |
| File Modified | 2019-09-19 |
| File Created | 2019-06-19 |