DAILY RECORD FORM FOR SCHOOL BREAKFAST
									   						Number of Days
Preparer’s Name ________________________________________________ School _______________________________________   of Operation______________________________
									or	      					  
Title__________________________________________________________  System_______________________________________

Year

Month
	Student Breakfasts	Adult Breakfasts	Total		

Free	
Workers
Free	

Reduced	
Workers
Reduced	

Paid	
Workers 
Paid	Total Number of Meals to
Children	
Free to Cooks	All 
Other
Adults	
Meal 
Count	
Milk
Served 	

Date
	
1a	
1b	
2a	
2b	
3a	
3b	
4	
5	
6	
7	
8	

												

												

												

												

												

												

												

												

Total												

1

EF-N-89     Rev.  10/01

RETAIN WITH MONTHLY REIMBURSEMENT CLAIM FOR 3 YEARS

Record on this form daily.  All food including milk, non-food supplies, and labor used.
FOOD
ITEM	
UNIT
SIZE	NUMBER OF UNITS USED	WEEKLY TOTAL USED	
UNIT COST	WEEKLY FOOD COST	

Week of		
M	
T	
W	
TH	
F				

										

										

										

Week of	

										

										

										

										
										
Week of	

										

										

										

2

ITEM	
UNIT
SIZE	NUMBER OF UNITS USED	WEEKLY TOTAL USED	
UNIT 
COST	WEEKLY FOOD COST	

Week of 		
M	
T	
W	
TH	
F				

										

										

										

										
Week of	

										

										

										

										

																			       FOOD
																			   MONTHLY
																			      GRAND
																			       TOTAL

Total Milk									MONTHLY		     MONTHLY
 MILK	       _	   Served       				 Cost per				     MILK		   +     FOOD		         =
SERVED	(Column 8)				   ½ pint			       =        TOTAL		         TOTAL

Food – For all items, including milk, record the amount used daily.  List all food costs associated with Breakfast.

3

OTHER

ITEM	
UNIT
SIZE	NUMBER OF UNITS USED	WEEKLY TOTAL USED	
UNIT COST	WEEKLY NON-FOOD
COST	

Week of		M	T	W	TH	F				

										

Week of	

										

Week of	

										

Week of	

										

Week of	

										

										

OTHER MONTHLY TOTAL

4

Non Food Supplies – Record paper and cleaning supplies used.  A code can be used daily to indicate which items are used and a cost can be assigned to each code.  e.g. NSC would indicate a napkin, straw and cup were used.  The number of units used would be the number of breakfasts served (Column 7) that day.  The cost for that combination could be calculated.  Another method is to mark supplies for breakfast and record the cost whenever a package is opened.  Each time a box of straws is opened for breakfast, record the price of one box.  This method does entail designating items for breakfast use only.

				      LABOR

EMPLOYEE NAME	HOURLY RATE	TOTAL HOURS	
Labor – The total cost is equal to the actual number of hours worked multiplied by the hourly rate plus payroll related costs (i.e. social security, sick leave, unemployment, retirement, holiday pay, workers’ comp, insurances and other fringe benefits, etc.) A percentage for related costs can be used.  If you do not know the actual percentage, use 20%.

SUMMARY OF 
BREAKFAST COSTS

FOOD		___________________________

LABOR	___________________________

OTHER	___________________________

TOTAL	___________________________

WEEKLY COST	
Week of				

				
Week of				

				
Week of				

				
Week of				

				
Week of				

				

					
			Total 				      
     LABOR
												   MONTHLY
										    +		     GRAND
										   		      TOTAL

PAYROLL RELATED COSTS ________%  X  _________Total (above) =		       =  

5

INSTRUCTIONS FOR COMPLETING FORM EF-N-89
SCHOOL BREAKFAST PROGRAM DAILY RECORD FORM

I.	Enter:		The person filling out the form must sign in the space provided to attest that the report is correct.
Title of person completing the form.
Name of School or System.
Number of breakfast meal service days during the calendar month.
Year, month and date column should cover the first through last day of the calendar month.
On the same line as the date, enter information under the proper columns.

II.	BREAKFASTS SERVED TO STUDENTS (Columns 1a – 4)

Column 1a – “FREE”   Students from families meeting the Federal eligibility standards for free meals.
Column 1b – “WORKERS FREE”  Students who work for their breakfast but qualify for free meals.
	          Add the monthly totals of Column 1a and 1b when completing the claim form.
Column 2a – “REDUCED”  Students from those families meeting the Federal eligibility standards for reduced price meals.
Column 2b – “WORKERS REDUCED”  Students who work for their breakfast but qualify for reduced price meals.  Add the monthly totals of Columns 2a and 2b when completing the claim form.
Column 3a – “PAID”  Students who have paid or charged their breakfasts.
Column 3b – “WORKERS PAID”  Students who work for their breakfast but do not qualify as free or reduced.  Add the totals of Column 3a and 3b when completing the claim form.
Column 4 – “TOTAL MEALS TO CHILDREN”   Add columns 1a, 1b, 2a, 2b, 3a, and 3b.

III.	BREAKFASTS SERVED TO ADULTS (Columns 5 & 6)

Column 5 – “FREE TO COOKS”  School lunch personnel and custodians, if applicable.
Column 6 – ALL OTHER ADULTS” paying for meals.

IV.	TOTAL

Column 7 – “MEAL COUNT”  The actual count of the number of meals served.  This should agree with the totals of Columns 4, 5, and 6.
Column 8 – “MILK SERVED”  Offer vs Serve schools can record here the number of meals served with milk.

6