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 the Site:_________________________________________________

Time Arrived: ____________  Time Departed: __________  Meal Observed: ____________  Approved Meal Time: _______ to _______

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?			____  ____   

Is site supervisor following sponsor 	____  _____  
procedures?

Are receiving reports and purchase
invoices kept?				____  _____  ____

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

Were meals served as second meals
excessive?				____  _____  ____

Are all meals served and consumed onsite?
(Note if fruits or vegetables are allowed to 
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, age or disability?			____  _____  

Do all children have equal access to 
services at the site regardless of race, color,
national origin, sex, age or disability?	____  _____  

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 meal served at a time to children.	_____	Required quantities of food items not served.

_____	Off-site meal consumption.			_____	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.
_____	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