school district name - region one esc powerpoint 3... · management (sam) . monetary incentives are...
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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
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
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
School HealthierUS School Challenge: SL Application 2
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
School HealthierUS School Challenge: SL Application 3
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
FNS HealthierUS School Challenge:Smarter Lunchrooms
School HealthierUS School Challenge: SL Application 4
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.
FNS HealthierUS School Challenge:Smarter Lunchrooms
School HealthierUS School Challenge: SL Application 5
FNS HealthierUS School Challenge:Smarter Lunchrooms
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.
School HealthierUS School Challenge: SL Application 6
FNS HealthierUS School Challenge:Smarter Lunchrooms
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.
School HealthierUS School Challenge: SL Application 7
FNS HealthierUS School Challenge:Smarter Lunchrooms
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
School HealthierUS School Challenge: SL Application 8
FNS HealthierUS School Challenge:Smarter Lunchrooms
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
School HealthierUS School Challenge: SL Application 9
FNS HealthierUS School Challenge:Smarter Lunchrooms
Physical Education Worksheet-Middle and High Schools
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.
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
School HealthierUS School Challenge: SL Application 10
FNS HealthierUS School Challenge:Smarter Lunchrooms
Physical Activity 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.
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 HealthierUS School Challenge: SL Application 11
FNS HealthierUS School Challenge:Smarter Lunchrooms
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.)
School HealthierUS School Challenge: SL Application 12
FNS HealthierUS School Challenge:Smarter Lunchrooms
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).
School HealthierUS School Challenge: SL Application 13
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.
FNS HealthierUS School Challenge:Smarter Lunchrooms
Other Criteria for Excellence Checklist Continued
School HealthierUS School Challenge: SL Application 14
FNS HealthierUS School Challenge:Smarter Lunchrooms
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
School HealthierUS School Challenge: SL Application 15
FNS HealthierUS School Challenge:Smarter Lunchrooms
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.
School HealthierUS School Challenge: SL Application 16
FNS HealthierUS School Challenge:Smarter Lunchrooms
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.
School HealthierUS School Challenge: SL Application 17
FNS HealthierUS School Challenge:Smarter Lunchrooms
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
School HealthierUS School Challenge: SL Application 18
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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)
Must have at least 50 items (or more) checked on
scorecard
Gold Award of Distinction Level Award
Must have at least 70 items (or more) checked on
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
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
o If all of the information cannot be seen in the text box, the
remaining information must be provided on a separate
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
o If all of the information cannot be seen in the text box, the
remaining information must be provided on a separate
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
classroom, cafeteria,& home/parents
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
classroom, cafeteria,& home/parents
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.
Must be within one year of date on HUSSC application
□ 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.
Must be within one year of date on HUSSC application
□ 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
remaining information must be provided on a separate
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