school district name - region one esc powerpoint 3... · management (sam) . monetary incentives are...

School District Name

General Information

Public reporting burden for this collection of information is estimated to average 2 hours per response,

including the time for reviewing instructions, searching existing data sources, gathering and

maintaining the data needed, and completing and reviewing the collection of information. An agency

may not conduct or sponsor, and a person is not required to respond to, a collection of

information unless it displays a currently valid OMB control number. Send comments

regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service,

Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not

return the completed form to this address.

Food and Nutrition Service

HealthierUS School Challenge:Smarter Lunchrooms

The HealthierUS School Challenge:Smarter Lunchrooms (HUSSC: SL) is a voluntary certification

initiative recognizing those schools enrolled in Team Nutrition that have created healthier school

environments through promotion of smarter lunchrooms, nutrition, and physical activity. Schools

receiving a HUSSC award will commit to meeting the criteria throughout their 4-year certification

period. Recognized schools receive a plaque with a certificate signed by the Secretary of Agriculture,

a display banner, recognition on the Team Nutrition Website, and a monetary incentive.

After being awarded, schools should work with their school district’s financial management/budget

staff to verify their DUNS Number and District’s Tax ID (EIN) Number within the System for Awards

Management (SAM) https://www.sam.gov. Monetary incentives are awarded on a quarterly basis and

once the school is formally announced as an award winner, a banking information request form will be

sent for the school district to complete by the end of that quarter. Submit the complete and

accurate form to USDA/FNS Team Nutrition staff for information verification and payment processing

via electronic funds transfer to the award-winning school(s). Incorrect or inadequate information

and the failure to ensure the information contained in the SAM is correct and current will delay

the processing of the funds payment to your district, and may even result in the elimination of

your ability to receive the award funds.

OMB APPROVED NO. 0584-0524

Expiration Date: 06/30/2016

School HealthierUS School Challenge: SL Application 1

http://www.sam.gov/

http://www.sam.gov/

General Information Continued

Tips for CompletingApplication:

1. You can submit your application two ways:

Submit the application and supporting documentation in a 3-ring binder to your State

Child NutritionAgency.

Submit the application and supporting documentation electronically to

[email protected]

2. When more space is needed to accommodate for additional days of the week or to provide

more information, schools and residential child care institutions (RCCI’s) can attach additional pages

as needed.

3. Multiple schools can apply under the same district application when all of the following

apply: The same nutrition education, physical education, and physical activities are

provided

or offered (according to the grade level).

The same Smart Snacks foods and beverages were sold throughout the cafeteria and/

or school campus. Submit:

a.) One Smart Snacks Worksheet with a listing of foods available and

b.) One set of supporting documentation.

Each individual school follows the district’s wellness policy.

In addition, each school within the District must submit a Smarter Lunchroom Self-Assessment Score

Card, individual School Wellness Policy Worksheet (if applicable) and complete the Other Criteria for

Excellence Checklist, which are both included in the application. If a district finds that their schools

has different nutrition education, physical education, physical activities, competitive foods,

or wellness policies, they can still apply as a district, but must make note of those items that

differ among the schools on the application worksheets and submit additional

documentation for those schools with the district application.

Each District must submit an Application Cover Sheet reflecting the name of the District with a

completed District School List form.

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Food and Nutrition Service

HealthierUS School Challenge:Smarter Lunchrooms


mailto:[email protected]

Application Cover Sheet

Application for: Bronze Silver Gold Gold Award of Distinction

* The school name on the Award Certificate will be typed exactly as written in the School Name

section below. Please ensure that the entire name with any appropriate punctuation is clearly

indicated. Award Certificates will not be re-printed due to an incorrect or illegible school name.

PRINT OR TYPE ALL INFORMATIONSchool Name

School District

School Address

Grades in School(list)

Contact Person’s

Name and Title

Contact Person’s

Phone Number& Email

Date Submitted to

State Agency

FOR OFFICE USE ONLY

State Agency

State Child Nutrition Director Approval:

Signature Date

Phone: Reviewed by:

Reviewer ’s Email:

Email of the State Child Nutrition Director:

Regional Office

FNS Region: Reviewed by:

Child Nutrition DirectorApproval:

Signature Date

FNS Headquarters

Reviewed by: Application received HQ:

Decision/Date: Award period:

FNS HealthierUS School Challenge:Smarter Lunchrooms


Table of Contents

Cover Sheet ..............................................................................................

Table of Contents .....................................................................................

General Criteria Worksheet .....................................................................

Smart Snacks Worksheet ........................................................................

Nutrition Education Worksheet ..............................................................

Physical Education Worksheet-Elementary Schools ............................

Physical Education Worksheet-Middle and High Schools ....................

Physical Activity Worksheet ....................................................................

School Wellness Policy Worksheet .......................................................

Other Criteria for Excellence Checklist .................................................

Review Committee Verification Form ....................................................

Application Check-off Sheet ...................................................................

3

4

5

6-7

8

9

10

11

12

13-15

16-17

18

Page Number



General Criteria Worksheet Yes No

Are you a Team Nutrition School? (check our Team Nutrition directory at:

http://teamnutrition.usda.gov/schoolsdb/srchpage.asp) Print and enclose a copy of each

school(s) Team Nutrition enrollment form. If your school is not a Team Nutrition School, complete the

Online Enrollment Form and submit a copy with your HUSSC application.

Have all corrective actions from your school’s most recent State review of your

school meals program been completed? If not, please contact your State Agency.

Is your school currently meeting school meal pattern requirements for the

National School Lunch Program and School Breakfast program as specified in 7

CFR 210 and 220?

Is your School Food Authority certified to receive the additional six cent

performance-based reimbursement (Healthy Hunger-Free Kids Act 2010)?

Is your school implementing Smarter Lunchroom techniques in six areas (Fruits,

Vegetables, Entrees, Milk, Sales of Reimbursable Meals, and School Synergies)

as defined on the Smarter Lunchrooms Self-Assessment Scorecard? The number

of techniques from the scorecard that the school must implement is dependent upon

the award level. Documentation that the school is meeting this

criteria shall include a copy of the completed score card and a brief summary with

2-3 photos describing the school’s overall Smarter Lunchroom effort.

items.

) criteria for

d Gold Award of Distinction, 20%

ion, 15% Silver

old Award of Distinction, 60% Silver

Silver

-Bronze applicants must select at least 30 action items.

-Silver/Gold applicants must select 50 action items.

-Gold Award of Distinction applicants must select 70 action

Does your school meet the Average Daily Participation (AD

breakfast and lunch?

No ADP requirement for Bronze.

Breakfast: Elementary and Middle School ADP: 35% Gold an

Silver High School ADP: 25% Gold and Gold Award of Distinct

Lunch: Elementary and Middle School ADP: 75% Gold and G

High School ADP: 65% Gold and Gold Award of Distinction, 45

P

%

List ADP for Breakfast calculated based on attendance:

Month/Year:

List ADP calculated for Lunch based on attendance: more info.Month/Year:

The State Agency and FNS reserve the right to verify all information on the application and reject

applications that are incomplete or otherwise fail to provide factual information.



http://teamnutrition.usda.gov/schoolsdb/srchpage.asp)


Smart Snack Worksheet

All Award Levels: Must meet Smart Snack in School Nutrition Standards. All

foods and beverages sold to students during the school day* meet or exceed

the USDA’s nutrition standards for all foods and beverages sold to students

(commonly called Smart Snacks in School.) This includes a la carte,

vending, school store, snack or food carts and any food-based fundraising (school follows

fundraising exemptions and guidance set by their State agency, which also must adhere to the

federal Smart Snacks in School requirements.)

Use the Smart Snack Calculator to analyze foods and beverages sold to students during the

school day (http://healthymeals.nal.usda.gov/smartsnacks). Provide a copy of the calculator

results, along with the product nutrition facts labels and ingredient statement with the HUSSC:

SL application.

Additional Smart Snacks Criteria

Bronze and Silver

Meets Smart Snacks criteria as defined in 7 CFR Parts 210 and 220.

The school offers training on Smart Snacks criteria annually and all individuals who are

involved in the sale of foods to students on the school campus during the school day. Use the

space provided below to briefly describe the training that is offered.

The school does not advertise or market foods and beverages that do not meet the

Smart Snacks criteria to students (e.g. signs and marketing materials promoting these

foods are not visible to the students on the school campus during the school day.)

Documentation of meeting these criteria includes evidence of a written policy and/or written

communication/training for school staff and parent organizations. Describe below how the

school meets these criteria and provide documentation with HUSSC: SL application.


http://healthymeals.nal.usda.gov/smartsnacks)


Smart Snack Worksheet Continued

Gold

Meets criteria for Bronze and Silver and

The school only permits food-related fundraisers that meet USDA’s Smart Snack

standards, even if the State allows exemptions. Provide a brief statement to explain how

the school meets these criteria with a list of food-related fundraisers and product labels and

ingredient statements (if applicable.)

If foods and beverages are sold to students on the school campus at events outside of

the school day (e.g. sporting events, after-school activities, award ceremonies), then

water, fruit, and/or vegetables are also offered and promoted as options. Documentation

of meeting these criteria includes a written school policy and/or instruction for those that sell

foods to students on the school campus. Provide a brief statement below and a copy of this

documentation and/or instructions with the HUSSC: SL application as evidence that the school

is meeting the criteria.

Gold Award of Distinction

Meets Gold Criteria and

The majority (greater than 50%) of school-sponsored fundraising events conducted

outside of the school day** includes only non-food items or only foods and beverages

that meet or exceed USDA’s Smart Snacks in School nutrition standards.

Documentation includes list of school-sponsored fundraisers during the past year and written

policy or guidance. Submit documentation with HUSSC: SL application.

List attached and documentation included with application.



Nutrition Education Worksheet

Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National

RecognitionAward from the Alliance for a Healthier Generation in lieu of completing this

section. Your HSP award must be dated within a year of your HUSSC: SL application.Elementary Schools:

Is Nutrition Education provided to all full-day students in all grades? Yes

Briefly describe below how nutrition education is provided to all students and:

No

Is part of structured and systematic unit of instruction.

incorporates Team Nutrition curricula and materials.

Middle and High Schools Gold and Gold Award of Distinction:

Briefly describe below how nutrition education is offered to:

Middle school students in at least two grades. Nutrition education offered must incorporate latest

Dietary Guidelines forAmericans and MyPlate and Team Nutrition materials.

High school students in at least two courses required for graduation. List the courses below. Nutrition

education must be part of a structured and systematic unit of instruction within the two courses. Nutrition

education must be consistent with latest Dietary Guidelines forAmericans and MyPlate.

Middle and High Schools Bronze and Silver:

Briefly describe below how nutrition education is offered to:

Middle school students offered in at least one grade. Nutrition education offered must incorporate latest

Dietary Guidelines forAmericans and MyPlate and Team Nutrition materials.

High school students in at least two courses required for graduation. List the courses below. Nutrition

education must be part of a structured and systematic unit of instruction within the two courses. Nutrition

education must be consistent with latest Dietary Guidelines forAmericans and MyPlate.

All grades and award levels should utilize multiple channels of communication, including classroom, cafeteria, and home/parents.

Describe below.

Grades Description of Nutrition Education Efforts Communication Channel Used



Physical Education Worksheet-Elementary Schools

Healthy School Program (HSP) Award Recipients: Submit a copy of your HSP National Recognition

Award from the Alliance for a Healthier Generation in lieu of completing this section.

Let’s Move Active Schools (LMAS) Award Recipients: Submit a copy of your LMAS Recognition

Award in lieu of completing this section.

Physical Education

Does your school provide physical education (PE) classes to all full-day students throughout the school

year? Yes NoBronze/Silver: A minimum average of 45 minutes* physical education per week.

Gold Award: A minimum average of 90 minutes* physical education per week.

Gold Award of Distinction: A minimum average of 150 minutes* physical education per week.

*Up to 45 minutes (Gold/Gold Award of Distinction,) *up to 20 minutes (Bronze/Silver,) of the PE

requirement may be met by providing structured physical activity planned by a certified PE teacher and

implemented by a classroom teacher or school administrator. All students must participate in the physical

activities, which must be at least moderate-intensity and in increments of at least 10 minutes. If utilizing the

structured physical activity option, you must provide a description below.

Physical Education Details

Grades

List the average number of minutes/week that physical education is provided throughout the school year for each grade specified Description of Physical Education Offered



Physical Education Worksheet-Middle and High Schools


RecognitionAward from the Alliance for a Healthier Generation in lieu of completing this section.

Let’s Move Active Schools (LMAS) Award Recipients: Submit a copy of your LMAS Recogni-

tion Award in lieu of completing this section.

Middle School: Briefly describe below how your school offers structured physical education classes

to at least two grades.

High School: Briefly describe below how your school offers structured physical education classes in

at least two courses. List the courses below.

Physical Education

Grades Description of Physical Education Offered



Physical Activity Worksheet


RecognitionAward from the Alliance for a Healthier Generation in lieu of completing this section.

Let’s Move Active Schools (LMAS) Award Recipients: Submit a copy of your LMAS

RecognitionAward in lieu of completing this section.

Physical Activity

Elementary Schools: Describe the additional daily physical activity opportunities provided to stu-

dents (such as recess). Indicate time allotted for any routine activities. If the physical activity was

used as “Structured Physical Activity” for counting towards the PE requirement, it cannot be listed

here also.

Middle and High Schools: Describe how school provides students in all grades opportunities to

participate in physical activity (intramural/interscholastic sports or activity clubs) and actively promotes

participation in physical activities to all students throughout the school year.

Physical Activity Details

Grades Describe Physical Activity Provided



School Wellness Policy Worksheet

Provide a copy of the school’s local wellness policy with the HUSSC: SL

application. If following a district wellness policy, provide a copy.

List three ways your school is working to meet School/District Wellness policy goals. For

example, completing and reporting the results of the School Health Index self-assessment process,

including local wellness policy goals in your school improvement plan, school wellness committee

meets every other month, etc.

1.

2.

3.

Describe how parents, students, school administration and staff, and the community are

involved in the implementation of the School/District Wellness policy at your school.

If your school has implemented wellness practices that are stricter than what is stated in your

school district’s local wellness policy, please explain.

(For example your school does not sell competitive foods.)

Briefly describe how your school demonstrates a commitment to neither deny nor require

physical activity as a means of punishment.

(For example, students who misbehave are not denied recess.)

Briefly describe how school demonstrates a commitment to prohibit the use of food as a

reward.

(For example, food is not used to reward students for good behavior or for the completion of an

assignment.)



Other Criteria for Excellence Checklist

Select from any option and submit supporting documentation with the

application:

Bronze: Must select at least two of the 14 options.

Silver: Must select at least four of the 14 options.

Gold: Must select at least six of the 14 options.

Gold Award of Distinction: Must select at least eight of the 14 options.

Program Outreach Excellence 3

School implements innovative practices to increase SBP participation, such as Breakfast in

the Classroom, Grab and Go options, or vended reimbursable breakfasts. Provide a brief

description and (if available) photo*.

School operates an afterschool program that participates in the Afterschool Snack

Program or at-risk afterschool meals component of the Child and Adult Care Food

Program (CACFP). Provide a brief description.

If percentage of free- or reduced-students is 50% or more, Summer Food Service

Program is available. Provide a brief description.

Implement the Community Eligibility Provision (CEP), if economically feasible.

(For more information on CEP, click on this link

http://www.fns.usda.gov/school-meals/community-eligibility-provision).


http://www.fns.usda.gov/school-meals/community-eligibility-provision)

Excellence in School and Community Involvement in Wellness Efforts 3

Provides annual training to before and afterschool program staff on physical activity and

nutrition. Provide a brief description.

All school staff receives annual training on wellness policies and ways to promote nutrition

and physical activity. Provide a brief description.

School partners with one or more community groups or SNAP Education providers to

promote wellness. Provide a brief description and include names of specific community

groups.

Students are engaged (via student advisory council, student wellness team, or similar

student interest groups) in wellness efforts and have the opportunity to provide input

on school food, marketing of school meals, and physical activity options. Input from

students (when feasible) should be taken and put into action. Provide a brief description.

School informs public on amount of time allotted for eating lunch. Solicits input from

students and community members on the amount of time that is adequate for eating

lunch. Provide a brief description.

The school offers an afterschool class, workshop, or club for students or families focused

on healthy cooking techniques. These types of events could take place weekly, monthly,

quarterly, or seasonally. Provide a brief description.


Other Criteria for Excellence Checklist Continued



Other Criteria for Excellence Checklist

School Food Service Excellence

School Food Service Manager is a certified food handler (local or national

certification). Provide a copy of certification.

School Nutrition Program Director meets or exceeds the minimum education

standards required by the Professional Standards final rule requirements.

Provide a brief description.

All school nutrition program directors, managers, and staff meet or exceed the

annual continuing education/training hours required by the Professional

Standards final rule requirements. Provide a brief description.

School is implementing at least one aspect of the Farm to School initiative

(schools may choose one or more):

Local and/or regional products are incorporated into the school meal program

Messages about agriculture and nutrition are reinforced throughout the learning

environment

School hosts a school garden

School hosts field trips to local farms

School utilizes promotions or special events, such as tastings, that highlight the

local/regional products.

Provide a brief description.

School has joined the U.S. Food Waste Challenge to recognize efforts to

reduce food waste. Provide a brief description.

3



Review Committee Verification Form

For individual school applications only

Please read the following statement and add your name and date below if you agree:

We have reviewed this application, and we agree that our school meals are healthy and appealing to

our students. We attest to the accuracy of the information provided in this application. We agree to

maintain the nutrition excellence, physical education/activity, and other criteria for excellence stan-

dards and procedures indicated in this application for the duration of our certification as HUSSC: SL

awardees. Furthermore, we agree to cooperate with USDA and other organizations upon request to

publicize our efforts.

Foodservice Manager’s Name/Address Email Address Date

Team Nutrition Leader’s Name Email Address Date

District Food Service Authority Name/Address

(Foodservice Director)

Email Address Date

Representative of the School’s Parent Organization Email Address Date

Physical Education/Health Teacher’s Name Email Address Date

Principal’s Name/Address Email Address Date

Please submit your completed application and documentation to your

State Child Nutrition Agency.

Public reporting burden for this collection of information is estimated to average 2 hours per response, including the

time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and

completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is

not required to respond to, a collection of information unless it displays a currently valid OMB control

number. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office

of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed

form to this address.



Review Committee Verification Form

For simplified school district applications only

Please read the following statement and add your name and date

below if you agree:

We have reviewed this application, and we agree that our school meals are healthy and appealing

to our students. We attest to the accuracy of the information provided in this application and attest

that it applies to all schools in the district unless otherwise noted. We agree to maintain the nutrition

excellence, physical education/activity, and other criteria for excellence standards and procedures

indicated in this application for the duration of our certification as HUSSC: SL awardees.

Furthermore, we agree to cooperate with USDA and other organizations upon request to publicize

our efforts.

Superintendent Name Email Address Date

District Food Service Authority Name/Address

(Foodservice Director)

Email Address Date

Representative of the District’s Parent

Organization Name

Email Address Date

Please submit your completed application and documentation to your

State Child Nutrition Agency.

Public reporting burden for this collection of information is estimated to average 2 hours per response, including the

time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and

completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is

not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Send comments regarding this burden estimate or any other aspect of this collection of information, including

suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Research

and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed form to this

address.



Application Check-off Sheet

Please include the following information in your Application:

Application Cover Sheet (pg 3)

Table of Contents (pg 4)

General Criteria Worksheet (pg 5)

Smart Snacks Worksheet (pg 6-7)

Nutrition Education Worksheet (pg 8)

Physical Education Worksheets (pg 9-10)

Physical Activity Worksheet (pg 11)

School Wellness Policy Worksheet (pg 12)

Other Criteria for Excellence Checklist (pg 13-15)

Review Committee Verification Form (pg 16-17)

Check-off Sheet (pg 18)

se submit the following additional docume

Copy of the School Wellness Policy (if school

Wellness Policy, please submit a copy).

Smart Snacks documentation including Allian

results, along with product nutrition fact label

Smart Snacks criteria have been met.

Completed Smarter Lunchrooms Scorecard a

ool District Financial Manager

Plea ntation:

does not have its own and follows a District

ce for a Healthier Generation Smart Snacks Calculator

s and ingredient statements or recipes to verify that the

nd Documentation

Sch

Name:

Email:

Phone Number:

Thank you for applying for the HealthierUS School Challenge: Smarter Lunchrooms

For more information, visit the Team Nutrition Website: www.teamnutrition.usda.gov


http://www.teamnutrition.usda.gov/

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Divider 1:

Application Coversheet (page 3 of application)

Documents

□ 1.Application Coversheet

If District application, no school name needed, provide district

name, central address for child Nutrition department

If individual school, provide campus name and address

Contact name/information should be the name/information of

individual who is completing and submitting the application

Please don’t fill out the Submitted to STATE AGENCY DATE

□ 2.School Directory (if District Application)

Make sure the information on the school directory matches

EXACTLY the information on EACH school(s) Team Nutrition

Enrollment Form

If district application, include each school’s ADP in the School

Directory

Divider 2:

General Criteria ( page 5 of application)

Required Documents:

□ 1.General Criteria Worksheet

If Single School application, fill out ADP

□ 2. Team Nutrition Enrollment Form(s)

Print out form for EACH school that is in application

Make sure the information on the school directory matches

EXACTLY the information on EACH school(s) Team Nutrition

Enrollment Form

□ 3. Implementing Smarter Lunchroom Techniques

Provide a copy of the Smarter Lunchrooms Self-Assessment

Scorecard(s) for EACH campus applying for HUSSC recognition

ALL AWARD LEVELS

Must have at least one item indicated on scorecard (box

checked) for each of the following scorecard categories

o Focusing on Fruits

o Promoting Vegetables and Salad

o Moving More white Milk

o Entrée of the Day

o Increasing Sales of Reimbursable Meals

o Creating School Synergies

Bronze Level award

Must have at least 30 items (or more) checked on

scorecard

Silver & Gold Level Award(s)


scorecard

Gold Award of Distinction Level Award


scorecard

Divider 3:

Smart Snack Worksheet (page 6 of application)

Required Documents:

□ 1. Use the Smart snack Calculator found on line at:o https://www.healthiergeneration.org/take_action/schools/snacks_and_beverag

es/smart_snacks/alliance_product_calculator/

□ Enter EACH item that may be sold to students during the school day

on the school campus in to the Calculator. This includes:

o Items sold a la carte

o Items sold in school stores

o Items sold in vending machines

o Items sold for fundraising

o Items sold on snack lines or carts

o Including but not limited to:

Snacks, Beverages, Entrees (except exempt entrees) and

Side dishes

Bronze and Silver Criteria

□ Smart Snack Training

o Provide a description in the box within the application OR on a

separate document describing how ALL staff involved in the

sale of food to students on the school campus during the

school day are trained ANNUALLY on the Smart Snacks criteria

o If all of the information cannot be seen in the text box, the

remaining information must be provided on a separate

document

□ Advertising and Marketing of Foods and Beverages

o Provide a description of how your district or school is meeting

the criteria for advertising of ONLY items that meet Smart

snacks criteria

o Provide a copy of the policy or communication/training which

supports this criteria

https://www.healthiergeneration.org/take_action/schools/snacks_and_beverages/smart_snacks/alliance_product_calculator/

https://www.healthiergeneration.org/take_action/schools/snacks_and_beverages/smart_snacks/alliance_product_calculator/

Divider 4:

Gold Criteria (page 7 of application)

Required Documents:

□ Meets all the Bronze and silver criteria

□ 1. Describe in the text box how the school or district meets the

criteria that all food related fundraisers meet the USDA Smart Snack

criteria

o `Include a list of all food related fundraisers held

o Provide product labels and ingredient statements as applicable



document

□ Describe in the text box how the school or district meets the criteria

that events held outside the school day at which foods and

beverages are sold include offerings and promotion of water, fruits

and/or vegetables as well

o Provide a copy of the documentation or instructions of how

this information is provided to all entities involved with these

sales



document

Gold Award of Distinction

Required Documents:

□ Meets all the Bronze, Silver and Gold criteria

□ Provide documentation indicating that >50% of all fundraisers

conducted outside the school day include only non-food items or

items that meet USDA smart Snacks Criteria

o Documentation includes a list of school sponsored fundraisers

for the past year and

o A copy of the written policy or guidance

Divider 5:

Smart Snacks Documentation

Required Documents:

□ 1 .Provide a copy of the printout from the Smart Snacks calculator

indicating the item meets criteria

□ Provide the actual label or a copy of the actual label for each item

sold OR

□ 3. Provide the recipe(s)

For mixed dishes

For items made from scratch

Recipes will need to include a nutrient profile

breakdown

\

classroom, cafeteria,& home/parents

Divider 6:

Nutrition Education Worksheet (page 8 of application)

Required Documents:

□ If a Healthy School Program Award Recipient, check the box and

make sure to include documentation of award.

Must be within one year of date on HUSSC application

□ Nutrition Education Worksheet

Elementary Schools: check yes or no box, then describe how

nutrition education is provided to all students and

1. Is part of a structured and systematic unit of instruction,

such as Team Nutrition Curricula or lessons.

2. Indicate the name of the curriculum used

3.Utilizes multiple channels of communication, including


Middle Schools: Briefly describe how nutrition education is

offered to:

1. Grade(s) level as part of a year round instruction, as

indicated by award level.

o Indicate grade levels

2. Utilizes multiple channels of communication, including


High Schools: Briefly describe how nutrition education is

offered in:

1. At least two courses required for graduation.

o List courses.

2. Utilizes multiple channels of communication, including

education is taught

Divider 7

Physical Education Worksheet(S) (pages 9 & 10 of application)

Required Documents:

□ If a Healthy School Program Award Recipient or Let’s Move Active

Schools Award Recipient, check the appropriate box and make sure

to include documentation of award.


□ Physical Education Worksheet

Remember* -Use the worksheet that corresponds with

application’s age/grade group.

Elementary Schools:

Check yes or no boxes

Check box next to award level of application

Indicate grade level(s)

List the average number of minutes per week that

physical education provided to each grade, as indicated

by award level.

Describe the physical education classes provided to all

students throughout the year.

Middle Schools:

Briefly describe how your school offers structured

physical education classes to at least two grades.

Indicate which grades physical education is provided to

High Schools:

Briefly describe how your school offer structured

physical education s in at least two courses

Provide the names of the courses where physical

Divider 8

Physical Activity (page 11 of application)

Required Documents:

□ If a Healthy School Program Award Recipient or Let’s Move Active

Schools Award Recipient, Check the box and make sure to include

documentation of award.


□ Physical Activity Worksheet.

Elementary Schools:

Describe the additional daily physical activity

opportunities provided to students (ex.Recess)

Indicate the time allotted for the daily physical activity

Middle and High Schools:

Describe how school provides students in all grades

opportunities to participate in physical activity(ex.

Intramural/interscholastic sports or activity clubs)

Describe how the school actively promotes participation

in physical activities to all students throughout the

school year.

Divider 9

School Wellness Policy Worksheet (page 12 of application)

Required Documents:

□ Copy of the school/district wellness policy

□ School Wellness Policy Worksheet

List three examples of how they are working to meet their

school/district wellness policy goals.

Fill out remaining 4 categories on page.

Divider 10

Other Criteria for Excellence (pages 13-15 of application)

Required Documents:

□ Provide description and supporting documents for each criteria

chosen

Bronze Criteria= 2 Option chosen

Silver Criteria= 4 Options chosen

Gold Criteria= 6 Options chosen

Gold with Distinction= 8 Options chosen

□ Providing documentation in text boxes

If all of the information cannot be seen in the text box, the


document

Divider 11

Review Committee Verification Form (page 16 OR 17 of application)

Required Documents:

□ Review Committee Verification Form

Use correct form either for school or district

Divider 12

Application Check-off Sheet (page 18 of application)

Required Documents:

□ Application Check-off Sheet

Provide requested information for the School District Financial

Manager

Name

Email address

Phone number