June 13, 2013
Non-Congregate Feeding for Outdoor Summer Site Report
Summer Food Service Program (SFSP) and Summer Seamless Option (SSO)
Those contracting entities (CEs) participating in the demonstration project for non-congregate feeding for outdoor summer feeding sites experiencing excessive heat must use this form to report information about each site’s non-congregate feeding under the project’s guidance.
Section 1: Contact Information
Name of Contracting Entity (CE): / CE Identification Number (CE ID): / Report Month/Year:
Site Name: / Site ID Number: / Site Location:
Section 2: Non-Congregate Feeding Information
Date / Type of NWS Issuance / Number of Meal(s) Served by Type / Signature of staff member attesting to information provided for this date:
Heat Advisory / Excessive Heat Warning / Excessive Heat Watch / Breakfast / AM Snack / Lunch / PM Snack / Supper
Total
Section 3: Certification
I certify, to the best of my knowledge, the information on this form is true and correct in all respects and that records are available to support the information. I know that deliberate misrepresentation or withholding of information may result in prosecution under applicable state and federal statutes.
Signature, Contracting Entity (CE) Authorized Representative: / ______/ Date: / ______
Printed or Typed Name of CE Authorized Representative: / ______/ Title: / ______
** Attach documentation for each National Weather Service Issuance for each day reported.
Instructions for
Non-Congregate Feeding for Outdoor Summer Site Report
Summer Food Service Program (SFSP) and Summer Seamless Option
This form is used to report meals served for a site when the CE exercises its option to use non-congregate feeding at outdoor summer sites when the National Weather Service (NWS) issues a Heat Advisory, Excessive Heat Warning, or Excessive Heat Watch under USDA’s demonstration project guidance.
(NOTE: Seamless Summer Option (SSO) CEs must register their intent to participate in the USDA demonstration project in the Texas Unified Nutrition Programs System (TX-UNPS) on the CE application and individual site application).
Section I: Contact Information
Name of Contracting Entity (CE)—Enter the name of the contracting entity in the designated box.
CE Identification Number (CE ID)—Enter the CE ID number for the contracting entity in the designated box
Report Month/Year—Enter the month and year for the information reported in this form in the designated box.
Site Name—Enter the name of the site that has opted to use non-congregate feeding under USDA demonstration project guidance in the designated space.
Site ID Number—Enter the site’s ID number in the designated space.
Site Location—Enter the site’s location in the designated space.
Section 2: Non-Congregate Feeding Information
Complete a separate form for each site that exercises the non-congregate feeding option.
Record the date the site opted to use non-congregate feeding because of an NSW alert in the designated space.
Record a check in the box for the NSW alert issued for recorded date for the site location—Heat Advisory, Excessive Heat Warning, or Excessive Heat Watch—in the designated space.
Enter the number of non-congregate meals served for the recorded date for each type of meal at the site—Breakfast, AM Snack, Lunch, PM Snack, and Supper—in the designated space/s.
Have the staff member providing the non-congregate feeding information for the recorded date attest to the accuracy of the information by signing in the designated box.
Total the number of non-congregate meals served for the month for each type of meal at the site—Breakfast, AM Snack, Lunch, PM Snack, and Supper—in the designated space/s.
(NOTE: If the number of non-congregate feeding dates exceeds the number of spaces on this form, sites should duplicate the form as appropriate.)
Section 3: Certification
Read the certification statement.
Have the CE’s authorized representative sign in the designated space to certify the accuracy of the information reported on this form.
Provide the date, printed or typed name of the CE’s authorized representative, and title of the authorized representative in the designated spaces.
Attach Documentation
Attach documentation that demonstrates the NSW issued an alert for each date for site has offered non-congregate feeding under the demonstration project.
Form Retention
Retain this form and documentation of the NSW issuance on file with the CE’s food production records.