FDACS-01706 Rev. 03/13

Florida Department of Agriculture and Consumer Services Division of Food, Nutrition and Wellness

You must conduct two onsite reviews. First one within first 4 weeks and the second onsite before end of the SY. You are not required to send a copy to the SA.

AFTERSCHOOL CARE SNACK PROGRAM ON-SITE REVIEW FORM

NICOLE "NIKKI" FRIED COMMISSIONER

Sponsor Name________________________________ Sponsor Number ________________________

Site Name___________________________________ Site Number ___________________________

Monitor’s Name____________________________________ Date _____________________________

Site Is: Area Eligible Non-Area Eligible

1. Describe the system for determining the eligibility status of children (non-area eligible sites only).________________________________________________________________________________________________________________________________________________________________

2. Describe the system for counting meals. Include statements regarding the identification, classificationand counting by category. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Describe the system for transmitting daily meal counts to the central office. ____________________________________________________________________________________________________

4. Is a daily attendance roster maintained? YES NO

5. Does the site have menus that document that reimbursable snacks are served? YES NO

6. Are snacks served as a unit? YES NO

7. Are the meal count procedures prepared by the sponsor and submitted to the Department of Agricultureand Consumer Services being followed? YES NO

8. Is the meal counting and claiming system adequate? YES NO

9. Is the “Justice for All” poster displayed in a prominent place visible by the students? YES NO

Comments: _____________________________________________________________________________ _______________________________________________________________________________________

Describe corrective action to be taken: ________________________________________________________ _______________________________________________________________________________________

________________________ _______ ______________________ _______ Signature of Site Supervisor Date Signature of Monitor Date

Date corrective action completed: ______ Date of follow-up review: ______

_______________________ _______ _______________________ _______ Signature of Site Supervisor Date Signature of Monitor Date

“In accordance with Federal law, and US Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.”

3-24-2011