SITE MONITORING REVIEW FORM

To be completed at each site/camp during the first four weeks of operation.

	
Site Name: ______________________________ Sponsoring Organization: ___________________________________________

Date of Review: ____________ Person Interviewed at Site: _______________________ Site Type (circle): Congregate   Non-Congregate            

Time Arrived: _______  Time Departed: ________           Meal Observed: __________        Approved Meal Time: _______________

MEAL COUNT
					
Number of meals delivered or prepared:		____
Number of leftover meals from previous day: 	____
Total Meals Available:				____
Eligible first meals to Children:			____
Eligible second meals to Children:			____
Meals to Program Adults:				____
Meals to Non-program Adults:			____
Meals Damaged or Incomplete:			____
Meals leftover:					____
Total Meals Accounted For:			____

Is meal production or ordering being	YES    NO    N/A
conducted with the intent of providing
one meal per child per day?		____   ____  ____  

Is site supervisor following sponsor 	____   ____  ____  
procedures?

Are receiving reports and purchase
invoices kept?				____   ____  ____  

Was the meal served within the 				
approved time frame?			____   ____  ____  

Were congregate meals served as second 
meals excessive?				____   ____  ____  

Are all congregate meals served and 
consumed onsite?
(One fruit, vegetable or grain item may be 
taken offsite).				____   ____  ____  

Is the required health department
certification available for inspection?	____   ____  ____  

Is proper sanitation in place?		____   ____  ____  

Has at least one person at the site
received sponsor training?			____   ____  ____  

Name of person(s) receiving training: 

___________________________________________________

MEAL COMPONENTS
Meat/Meal Alternate:	______________________________
Meat/Meat Alternate:	______________________________
Bread/Bread Alternate:	______________________________
Fruit/Vegetable:		______________________________
Fruit/Vegetable:		______________________________
Fruit/Vegetable:		______________________________
Milk:			______________________________
Other:			______________________________

Does the meal appear to meet		YES    NO    N/A
meal pattern requirements?
					____   ____  ____  
Are accurate counts of meals 
being taken?				____   ____  ____  
	
Are records of adult meal kept? 		____  _____  ____

Is there documentation of children’s
income eligibility, if applicable?		____   ____  ____  

Is there an “And Justice For All” 
poster on display?			____   ____  ____  

Are meals served to all attending children 
regardless of race, color, national origin,
sex (including gender identity and sexual
orientation), disability or age?		 ____   ____  ____  
  
Do all children have equal access to 
services at the site regardless of race, color,
national origin, sex (including gender 
identity and sexual orientation), disability
or age?	  				____   ____  ____  

Does site have sufficient food service 
supervision?				  ____   ____  ____  

Are leftover meals handled appropriately?	  ____   ____  ____  

Are meals counted and checked before 
signing delivery receipt?			  ____   ____  ____  		
More on back of page 

SITE MONITORING REVIEW FORM – Page Two

DEFICIENCIES: (Please check, if applicable)
_____	More than one congregate meal served at a time to children.   _____Required quantities of food items not served.

_____	Off-site meal consumption at congregate site.	    _____ Meals served outside of approved time frame.

_____	Meals not served as a unit.				    _____ Adult meals included in count of meals to children.

_____	Meal count records not being maintained.		    _____	Site environment and/or food handling procedures
								are unsanitary.
_____	Non-congregate procedures not being followed.

_____	Other: ________________________________	

Corrective Action Discussed with (name and title):  ______________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Site Supervisor’s Comments:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Further Action needed by: _______________________________________________________________

I certify that the above information is correct:

________________________	             ___________________________     
Site Supervisor’s Signature						Sponsor Representative’s signature

____________          						            _____________
Date								            Date