School COVID-19 Intake Form

School COVID-19 Intake Form
Any schools that have closed due to COVID-19 and are providing meals to students must report to TDA specifics regarding meal service activities. By completing this form, you are:
- Opting in to serve non-congregate meals via the Summer Food Service Program (SFSP) or Seamless Summer Option (SSO).
- Indicating intent to waive mealtime restrictions.
You must submit this form before claiming any non-congregate meals. TDA will only contact you if we have any questions but will indicate completed receipt of this form in TX-UNPS Packet Notes.

NOTE: You are not approved to operate until your COVID-19 site application has been submitted and approved.

Please complete this form as applicable.
CE Name*
CEID*
5-digit CE ID from TDA (ex: 00522)
When did meal service start?*

MonthDayYear
Date
Meal Program Used*

SFSP (Summer Food Service Program)SSO (Seamless Summer Option)
Are you serving non-congregate meals?

YesNo
Who is receiving meals? Check all that apply.

ChildrenAdultsMultiple methods (varied per site)
How will food be provided? Check all that apply.

Household deliverySite distribution (grab & go)Multiple methods (varied per site)
What quantity of food will be served? Check all that apply.

One (1) meal per student per meal period (specify meals/snack)Multiple meal types (ex: breakfast and lunch served at the same time)Multiple days of food provided at one time (specify days)Multiple methods (varied per site)Other
Specify days if multiple days of food will be served at one time.
Is your district electing to offer one age/grade group meal pattern related to portion size for open sites and open restricted sites?

YesNo
What method are you using to communicate to families about meal availability?

Press ReleaseEmailsOther
In the text box below, explain your Food Distribution Plan in detail. Include:
1. How you will target low-income children
2. How you will document meal content
3. How you will record meal count
4. How you will ensure food safety
5. How multiple meals served at one time will be tracked
Food Distribution Plan
Refer to prompt above for point to cover.
TDA may contact you with additional questions. Identify a contact responsible for responding to all TDA follow up required for COVID-19.
CE Contact Name*

First NameLast Name
CE Contact Email Address*
example@example.com
CE Contact Phone Number*

Area CodePhone Number
A copy of your submitted responses will be emailed to the Contact Email address above. Please print and retain the automated email receipt for your records.
Should be Empty:

School COVID-19 Intake Form

A copy of your submitted responses will be emailed to the Contact Email address above. Please print and retain the automated email receipt for your records.