Title Page

  • Conducted on

  • Prepared by

  • Location (Center Address)
  • Classroom

  • Person Contacted At Facility

  • Visit Type

  • Approved Meal Service Time Listed on Schedule A

  • Observed Meal

  • Time Meal Served

  • (1) Do meal(s) observed meet all USDA component<br>requirements as listed in Schedule B?

  • (2) Do meal(s) observed meet all USDA portion size<br>requirements as listed in Schedule B?

  • (3) Do infant meals meet all USDA component and portion<br>size requirements as listed in Schedule B?

  • (4) Are meal counts taken at the point of meal service for<br>all meals served to enrolled participants on the CACFP<br>Standardized Meal Count Form?

  • (5) Are meal counts taken at the point of meal service for<br>all program staff?

  • (6) Is there a dated menu available for the meal observed?

  • (7) Are attendance records available for all enrolled<br>participants?

  • (8) Is the Child And Adult Care Food Program Eligibility<br>Application on file for each participant?

  • (9) Is the facility currently licensed?

  • (10) Does the facility have a current health and sanitation<br>certificate?

  • (11) Does the facility have a current fire and building<br>inspection certificate?

(12) Have facility personnel been trained in the following CACFP requirements?

  • CACFP Eligibility Requirement

  • Monitoring Enrollment/Eligibility

  • USDA Component Requirements

  • USDA Portion Size Requirements

  • Attendance Procedures

  • Meal Count Procedures

  • Meal Service Procedures

  • Civil Rights Procedures

  • (13) List the additional training area(s) that facility personnel need:

(14) List the components of the observed meal:

  • Milk

  • Juice, Fruit or Vegetable

  • Bread / Bread Alternate

  • Fruit or Vegetable

  • Meat / Meat Alternate

  • (15a) Does the observed meal meet the minimum USDA requirements as specified in the Child and Adult Care Food Program, Schedule B?

  • (15b) Does the facility serve meals to infants?

  • (15c) List food items provided by the facility and/or parent

  • Formula or Breast Milk

  • Infant Cereal

  • Infant Meat or Meat Alternate

  • Infant Fruit or Vegetable

  • (16) 5-Day Reconciliation and Meal Count Variation Review
  • Review the five (5) previous days for the SAME MEAL SERVICE and list the total meal counts, attendance and enrollment figures.

  • Date

  • Meal Count

  • Attendance

  • Eligibility/Enrollment

  • If Vended, List # Meals Delivered

  • Do the attendance and enrollment/eligibility records support the meal counts?

  • Do the meal counts show variation for the 5-day period?

  • If No, continue to review 10 additional days (for a total of 15 consecutive days) for THE SAME
    MEAL SERVICE, and list the total meal counts, attendance and enrollment figures.

  • Date

  • Meal Count

  • Attendance

  • Eligibility/Enrollment

  • If Vended, List # Meals Delivered

Findings

  • List Findings Identified during Last Review.

  • Current Findings:

  • Technical Assistance Provided / Corrective Action(s):

  • Additional Comments

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