Declare or Decline Summer 2021 SY 2021-2022

Part 2: Waiver Options

4. Non-Congregate Feeding

Please answer the following questions about your usage of the Non-Congregate waiver

4-1: Select any non-congregate meal distribution methods any of your sites plan to use (check all that apply):*

	Yes	No
Walk-up sites at schools, centers, or other buildings
Curbside pick-up/drive-through service
Mobile sites at which a bus or van delivers meals at pre-set times
Delivery with stops at individual homes
Other delivery methods

4-2: Please describe the other delivery methods you will use:

4-3: Please select any meal counting methods any of your sites plan to use (check all that apply):*

	Yes	No
Standard point of service system
Mobile technology (for example, laptop, table, or cell phone apps)
Paper rosters
Clickers
Other counting method

4-4: Please describe the other counting methods you will use:

4-5: Indicate the program(s) where you used or will use the Non-Congregate Waiver:

4-5.

SSO

4-5.

NSLP

4-5.

SFSP

4-5.

SBP

4-5.

NSLP Afterschool Care Program (ASCP)

4-5.

CACFP At-Risk Afterschool Care Program

4-5.

CACFP Day Care Home Sponsor

4-5.

CACFP Independent Center

4-5.

CACFP Child Care Center Sponsor

4-5.

CACFP Adult Day Care Home Sponsor

5. ALTERNATE MEALTIME OPTIONS

Please answer the following questions about your usage of the Alternate Mealtime waiver

5-1: Select the meal options that any of your sites plan to use (select all that apply):*

	Yes	No
Meals for the day distributed at one daily distribution
Full week (5 days) distributed at one time
2-4 days of meals distributed at one time
Weekend meals
Bulk food component distribution*
Frozen meals
Shelf-stable meals

field calculation

5-2: Indicate the programs where you will used or will use the Alternate Mealtime Waiver:

5-2.

SSO

5-2.

NSLP

5-2.

SFSP

5-2.

SBP

5-2.

NSLP Afterschool Care Program (ASCP)

5-2.

CACFP At-Risk Afterschool Care Program

5-2.

CACFP Day Care Home Sponsor

5-2.

CACFP Independent Center

5-2.

CACFP Child Care Center Sponsor

5-2.

CACFP Adult Day Care Home Sponsor

*Selecting bulk food component distribution requires TDA approval. Upon submittal of this form, you will be directed to the Bulk Food Component Distribution form. HOWEVER, if you have already submitted the Bulk Food Component Distribution Form, you need to only confirm that you will use this waiver.

6. NO CHILD PRESENT/PARENT PICK-UP OPTIONS

Please answer the following questions about your usage of the No Child Present/Parent Pick-Up Waiver.

6-1: Select the methods any of your sites will use to implement this waiver and identify guardianship (check all that apply):*

	Yes	No
Scan children’s meal cards or ask for children’s personal identification numbers used for meal service
Request children’s names, ages or dates of birth, or grade levels when meals are picked up
Request children’s school names or a copy of school correspondence when meals are picked up
Request the number of children for which the parent/guardian is picking up meals
Provide parents/guardians with rearview mirror hangers, placards, or QR codes
Post signage to indicate who is eligible to pick up and receive meals
Other methods to ensure meals are distributed only to parent/guardians of eligible children

6-2: Please describe the other methods you will use to implement this waiver and identify guardianship:

6-3: List any methods your sites plan to use to discourage service of duplicate meals (check all that apply):*

	Yes	No
Tell parents/guardians picking up meals that children are not eligible to receive duplicate meals
Ask parents/guardians to self-attest that they are not picking up duplicate meals
Request children’s names or other identifying information when meals are picked up
Used the same staff at multiple delivery sites (that provided meals at different times) located in a geographic area
Other methods to ensure duplicate meals are not distributed

6-4: Please describe the other methods you will use to discourage service of duplicate meals:

6-5: Indicate the programs where you used or will use the No Child Present/Parent Pick-up Waiver:

6-5

SSO

6-5

NSLP

6-5

SFSP

6-5

SBP

6-5

NSLP Afterschool Care Program (ASCP)

6-5

CACFP At-Risk Afterschool Care Program

6-5

CACFP Day Care Home Sponsor

6-5

CACFP Independent Center

6-5

CACFP Child Care Center Sponsor

6-5

CACFP Adult Day Care Home Sponsor

7. OFFSITE MONITORING OPTIONS

Please answer the following questions about your usage of the Offsite Monitoring waiver

7-1: Select the methods any of your sites will use for offsite monitoring (check all that apply):*

	Yes	No
Desk audit-paperwork review
Desk audit- interviews with site operators
Virtual observations conducted through live stream video
Virtual observations through review of site photos
On-site while assisting with or observing meal service
Other types of monitoring

7-2: Please describe any other methods of monitoring that you will use:

7-3: Confirm the program(s) used or will use for Offsite Monitoring

7-3

SSO

7-3

NSLP

7-3

SFSP

7-3

SBP

7-3

NSLP Afterschool Care Program (ASCP)

7-3

CACFP At-Risk Afterschool Care Program

7-3

CACFP Day Care Home Sponsor

7-3

CACFP Independent Center

7-3

CACFP Child Care Center Sponsor

7-3

CACFP Adult Day Care Home Sponsor

8. Offer versus Serve

Please answer the following question about your usage of the Offer versus Serve waiver

8-1: Select the Program for which you will NOT implement OVS at one or more of your senior high schools during SY 2021-22:

8-1

SSO

8-1

NSLP

8-1

SBP

9. Waiver Impact

Please answer the following questions about the impact of using waivers.

9-1: For any of the waivers you have selected, please indicate the impact that you believe these waivers have:*

	High Impact	Some Impact	No Impact or Not Applicable
Improve participant's access to meals
Improve access to meal sites
Improve the safety of participants
Improve the safety of staff
Ease meal preparation
Ease meal delivery
Help manage meal service costs
Reduce the administrative burden
Focus resources on identifying meal sites
Focus resources on providing meals
Focus resources on other priority areas

9-2: Are there any other impacts that the waivers have?

Declare or Decline Meal Service Options

Part 1: Waiver Selection

2. Select the program(s) that you operate

Part 2: Waiver Options

10. Select the month from the drop-down field for any waiver that you will no longer use in any program and any site.

Part 3. Contracting Entity Information