Nutrition Site Assessment

Nutrition Site Assessment

FY 2013NUTRITION SITE ASSESSMENT

TOTAL MEALS:

DATE TIME SITE AAA 1-B Nutrition Contracts Manager, RD:Karen Jackson Holzhauer, ______

NAME OF PROGRAM SITE MANAGER Daily Hours of Operation

CONGREGATE/ADHS MEALS one two three HOME DELIVERED MEALS one two three

DAYS/WEEK:Mon.Tue. Wed. Thu. Fri. Sat. Sun.TotalMealsServed Today: Comments: ______

MENU MARKETING

/

SERVING STYLES & EQUIPMENT

AAA 1-B Congregate Poster displayed: Yes No Other: / Served at tables, by staffFamily style
Suggested donation: $Guest fee: $ / Cafeteria, by staffBuffet: Self-Serve By staff
Menu posted:Daily Weekly Monthly No / Salad Bar Soup Bar
Other (i.e., proportioned, )
Menu corresponds to meal served:Yes No / Equipment used to maintain temperatures until serving time:
Nutrition education literature current:Yes No / CarriersChafing Dishes

DONATION SYSTEM (check all that apply)

/ Oven/StoveSteam Table
Private: Yes No Total amount recorded today: $ / Comments:
Location (Check One):Entrance Table Container Envelope /

TODAY’S MENU/APPROVAL Yes (Date:) No

Other (Describe): / Menu Cycle Length: Food Item Temperature
Guests Pay:Yes Amt: $ No , / Meat / Alternative (2/3 ounces)135 /
Staff Pay:Yes Amt: $ No / Fruit / Vegetables (2 servings ½ c.)40 / 135 /
Volunteers Pay:Yes Amt: $ No / Fruit / Vegetables (2 servings½ c.)40 / 135 /
How is payment recorded: / Bread or Equivalent (2 servings)40 / 135 /
Receipts provided: Yes (attach sample form)No / 1 tsp Fat / Condiments / Salad Bar 40 /
Sign-in sheets/Cancellation:Yes (attach sample form)No / Milk (8 ounces) Skim, ½ % , Low Fat 1%, 2%, Whole 40 /
FOOD PREPARATION / DELIVERY (check all that apply) / Meals uniform in portion:Yes No
On-site Caterer (Name:) Central Kitchen / There is enough food:Yes No Leftovers?Yes No
Food License Current? Yes (Date) No Posted:Yes No / What was done with the leftovers?
Certified Manager on duty?Yes (Date: Name: )No / Food labeled/dated:Yes No
Health report compliance?Yes (Date report on file: )No / One-year menu on file:Yes No location:
Food delivery time:___Temps recorded: Yes No
Serving time: Begin EndTemps recorded: Yes No / Nutritional Analysis Software: Yes No ______
Site Survey Updated: Customer Satisfaction Survey:Attach Sample

FOOD QUALITY STANDARDS

SITE FILES/ACTIVITIES

/ ColorYes No Portion Yes No
Current participant intake files present:Yes No / TextureYes No Vitamin C Yes No
Files locked/secured/password protected Yes No / TasteYes No Vitamin A Yes No
Describe programming on-site below: Yes No / AromaYes No Kcal Yes No
AppearanceYes No Sodium Yes No
FiberYes No Recipe Adherence Yes No
Contractor/Vendor Comments(i.e. , Activities on Site, Nutrition Education Display, Nutrition/Ingredient Analysis Available, Meal Reservation/Forecasting)

AAA1-B Comments (i.e., Observations from Meal Assembly/Service, Customer Comments, Dining Area, Site Access)

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