School Data Worksheet for Verification Effort
SCHOOL DATA WORKSHEET FOR VERIFICATION EFFORT
(Internal School Document)
This form is best used by those schools that do not have an electronic Applications system.
The information on this form must be consolidated for all SAU/RA schools onto the Verification Summary Report submitted by the SFA. If it appears that you will not be able to complete the verification effort process by November 15, 2011. An extension waiver for school year 11-12 may be granted by submitting the Verification Effort Plan of Action Form to the Bureau of Nutrition Programs and Services. The waiver request must be submitted to the Bureau of Nutrition Programs and Services, 101 Pleasant Street, Concord, NH 03301 by October 28, 2011.
SFA #: SCHOOL/INSTITUTION NAME: SCHOOL YEAR:
Total # of applications chosen for verification (CURRENT year): / ______SECTION I: Method used for Verification Selection
Step A:
1. Total number of applications from PREVIOUS year chosen for verification: / ______
2. Total number of applications from PREVIOUS year that were denied eligibility because of Non-
Response: / ______
3. The percentage of applications from PREVIOUS year in relation to the total number of PREVIOUS
year denied applications: (EX.: # 1. total= 6, # 2. total = 3; the percentage of denied applications for # 3. is 50%) / ______
NOTE: If the percentage of denied applications from the PREVIOUS year is equal to 20% or more, you must follow procedures for Standard Sample Size- Error Prone (page 68 of the Eligibility Manual for School Meals, Jan. 2008)
Step B: Based on the answer to # 3 in Step A, check the box below that represents the verification method your school
has chosen:
o Standard Sample Size (20% or more of denied applications from PREVIOUS year)
o Alternate Sample Size is equal to or less than
o 1. 3,000 of all applications 10/01 OR 3% of total applications on file 10/01
o 2. 1,000 of all applications as of 10/01 selected from error prone, OR
1% of all applications selected from error prone applications 10/01 PLUS
the lesser of: 500 applications as of 10/01 that provide a case number in lieu of income
OR ½ of 1% of applications as of 10/01 that provide a case number in lieu of income.
SECTION II: Summary of School Verification Efforts – CURRENT YEAR
Numbering system corresponds to SFA Summary Report
2a. Number of schools & RCCIs operating the NSLP and/or SBP as of 10/1/11. / ______
2b. Provision 2 or 3 schools which are not operating a base year. / N/A
3a. Number of enrolled students having access to NSLP/SBP as of 10/1/11. / ______
3b. Provision 2 or 3 schools which are not operating a base year. / N/A
t COMPLETE BACK SIDE OF FORM u
4-1a. through 4-4a.) / ______
4-1a. / Number of students approved as Free eligible who are NOT subject to verification as of 10/1.*
(See Exceptions from Verification Requirements on right for those that are NOT subject to verification.) / ______/ *4-1a: Exceptions from Verification Requirements: Direct Certification children, children documented as eligible migrant, runaway, or homeless as identified on liaison list, RCCI students except day student w/ application, collateral applications, non-pricing programs, schools only participating in the Special Milk Program.
4-2a. / Number of students approved as Free, based on
FS/FANF case # submitted on an application as of
10/1. (Categorically Eligible) / ______/ 4-2b. / Number of approved applications Free, based on FS/FANF case # submitted on an application as of 10/1. (Categorically Eligible) / ______
4-3a. / Number approved students as Free based on
income/household size as of 10/1. / ______/ 4-3b. / Number of approved applications Free based on income/household size as of 10/1. / ______
4-4a. / Number Free eligible reported by Provision 2 or 3 schools which is not operating a base year as of 10/1. / N/A
5a. Number of Reduced Eligible students as of 10/1. / ______
5b. Number of approved applications for Reduced eligible students as of 10/1. / ______
5-1a. Number reduced eligible reported by Provision 2 or 3 school which is not
operating a base year. / N/A
Section III: Verification Results
FREE ELIGIBLE
Based on FS/FANF/FDPIR
Application (Categorical Eligible) / FREE ELIGIBLE
Based on Income/ Household Size Application (Income Eligible) / REDUCED
PRICE
ELIGIBLE
7. No Change / # applications
# students
8. Responded, Changed to Free / # applications
# students
9. Responded, Changed to
Reduced Price / # applications
# students
10. Responded, Changed to Paid / # applications
# students
11. Did Not Respond / # applications
# students
Optional
12. Reapplied and Re-approved
on or before Feb. 15 / # applications
# students
DO NOT SEND THE SCHOOL DATA WORKSHEET
DOCUMENT TO THE STATE OFFICE
Reviewed 09/2011