North carolina Departm€nt of Health and Human
Handout
s€rvices
#I
Division of Public Health
Women's & Children's Health Section
Special Nutrition Programs
SUMMER FOOD SERVICE PROGRAM (SFSP)
SPONSOR APPLICATION
PREAWARD COMPLIANCE
Agreement #:
Sponsor Name:
'the following information must be included in the Sponsor Application.
l.
Estimate data on the ethnic and racial makeup of the pqlglllially illgihlg population to be served. Please
enter the number ofindividuals, not the percentage ofthe potentiallv eligible population to be served.
f,thnicity:
Hispanic or Latino
Not Hispanic or Latino
Race:
American Indian or Alaskan Natrvc
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
2.
Describe the efforts to be used to assure that minority populations have an equal opportuniry to participate.
3.
Describe efforts to be used to contact minority and grassroots organizations about the opportunity to
oarticioate.
4.
List any Federal agencies currently providing financial supporl to the institution.
4a. Has the Sponsor ever been found to bc in noncompliancc by those Federal agencies? Il'ycs.
explain and provide dates.
Nutrition Sewices Brdroh
SI:SP
2014 SF'SP Pr€-Alyard ComDliance (11/13)
Pagc I
ol
I
Handout #2!
ETHNIC AND RACIAT DATE FORM
Sponsor Name:
Agreement Number:
Site Name:
Site Address:
Ethnic coteqories
Hispanic or Latino:
A person of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish culture or origin, regardless of race,
Not Hispanic o. Latino:
All persons not fitting in the above category.
Number of Children
Roce Cotegories
Number of Children
American Indian or Alaska native:
A person having origins in any of the original people of North
and South America (including Central America), and who
maintains cultural identification through tribal affiliation or
community recognition (includes Aleuts and Eskimos)
*lndividuols of the Hisponic or Lotino Ethnicity ore considered
port of the Americon lndion or Aloska ndtive Roce.
Asian:
A person having origins in any of the original people of the Far
East, Southeast Asia, or the Indian subcontinent, including, for
example, Cambodia, China, Japan, Korea, Malaysia, Pakistan,
the Philippine lslands, Thailand, and Vietnam.
Black or African American:
A person having origins in black racial groups of Africa
Native Hawaiian or Other Pacific lslander:
A person having origins in any o the original peoples of Hawaii,
Guam. Samoa, or other Pacific lslands
White:
A person having origins in any of the original peoples of
Europe, North Africa, or the Middle East.
Sponsor's Authorized Representative
4'" week Monitor Review
Revised 10/26111
Date
Original: Keep on File, Copy: Site Supervisor
Handout #2b
Instructions for Completing the Ethnic Racial Data Form
o
The Sponsor/Sponsor Representative should complete the is form for EACH site every year
o
The Sponsor/Sponsor Representative may use visual identification to determine a participant's racial
and/or racialcategory. A participant may be included in the group that he/she appears to belong,
identifies with, or is regarded as a member by the community.
.
.
o
Each participant should be counted under only one category for
ethnicity. The total number of
participant marked under the ethnic category should equalthe total number of participants in
attendance on the day the form was completed.
Each participant maybe be counted under more than one category
for race. The total number of
participants marked under the race category may be larger sum than the total number of participants
in attendance on the day the form is completed.
The Sponsor/Sponsor Representative must retain ethnic and racial date for 3 years and must safeguard
this information. Access to Program records containing racial/ethnic date should be limited to
authored personnel only.
4'" week Monitor Review
Revised 10/25l11
Original: Keep on File, Copy: Site Supervisor
Handout
#3
SAMPLE CONFIDENTIALITY POLICY
Purpose
To establish a protocol to prevent unauthorized persons access to confidential data.
Policy
l.
2.
3.
The
shall maintain all data in the strictest confidence.
(lnsert title of responsible party)
All records containing confidential information will be maintained securely in locked
files accessible onlv to reoresentatives of
(lnstitution's Name).
Ethnic and racial data are used for reporting purposes only and are not used for any
discrim inatory purposes.
Procedures
l.
The following data is collected for each participant upon enrollment and annually
thereafter while pafticipating in the Child and Adult Care Food Program (CACFP)
and is considered confidential.
.
o
.
2.
Ethnic Data
Racial Data
Income Eligibility Data
Data is stored in
3.
Access to data is restricted to the following
_
(specify location)
staff(list positions with
access to data):
4. Ethnic and racial dala is used for reporting purposcs only.
5. Data collected will be maintained on file for 3 years.
6. At the end ofthe retention period, data shall be destroyed on site (for example:
shredded and discarded).
Sample Confidentiality Policy 1/l 2
Handout # 4a
Summer Food Servicc Program- MEDIA RELEASE
-
Open Sites
AGREEMENT NUMBER:
SPONSOR CONTACT NAMf,:
SPONSOR CONTACT NUMBf,R:
lhe
(Namc ol'Sponsor)
Program. Meals will be provided to all children without charge and are the same for all children regardlcss of
race, color, national origin, sex, age or disability, and there will be no discrimination in the course of the rncal
service. Meals will be provided at the sites and times as follows:
Meals will be provided at the sites and times as indicated on the attached page(s).
To file a Civil Rights program complaint of discrimination, wrile or call immediately to:
U.S. Department of Agriculture, Director
Office ofAdjudication
1400 Independence Avenue, SW
Washington, D.C. 20250 -9 4 | 0
(866) 632-9992 or (800) 877-8339
(rrY)
Or complete the USDA Program Discrimination Complaint Form, found online at
http://$ w$.ascr.usda.gov/colnplaint fi Iing_cusl.html.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the
Federal Relay Service at (800) 8'77 -8339: or (800) 845-61 36 (in Spanish).
USDA is an equal opportunity provider and employer.
Sponsor Use Only
Sent
To: Media Outlets
Date:
/
(mm/dd/yvyv)
Routing: Submit original to media outlet and one copy to State Agency. Relain one copy lor your files. ( l2l13)
Handout # 4a
Summer Food Service Program- MEDIA RELEASE
Site Address and Phone
Name of Site
Contact Person
Number
-
Opcn Sites
Start Date/
End Date
Meal Service
Start Time
Meal Service
End Time
USE ATTACHMENT SHEETS IF NECESSARY
Routing: Submit original to media outlet and one copy to
State Agency. Retain one copy for your
filcs. (12l13)
Handout #4b
Summer Food Service Program- MEDIA RELEASE
-
Camps and Closed Enrolled Sitcs
AGREEMENT NUMBER:
SPONSOR CONTACTNAME:
SPONSOR CONTACT NUMBER:
is participating in the Summer Food Service
The
(Namc ol'Sponsor)
Program. Meals will be provided to all eligible children free ofcharge. To be eligible to reccive free meals at a
residential or non-residential camp, children must meet the income guidelines for reduced-price meals in the
National School Lunch Program. The income guidelines for reduced price meals by family size are below.
Foster children and children who are part of households that receive Food and Nutrition Services (FNS),
otherwise known as Supplernental Nutrition Assistance Prograrr (SNAP, forrnerly foods stamps) bencflts, or
benefits under the Food Distribution Program on lndian Reservations (FDPIR), or Temporary Assistance to
Needy Families (TANF) are automatically eligible to receive free meals.
Acceptance and participation requirements for the Program and all activities arc the same for all regardless of
race, color, national origin, scx, age or disability, and there will be no discrirnination in the course of thc meal
service.
Meals
will
be provided at the sites and times as indicated on the attached page(s):
To file a Civil Rights prograrn complaint of discrimination, write or call immediately to:
U.S. Depaftment of Agriculture, Director
Office of Adjudication
1400 lndependence Avenue, SW
Washington, D.C. 20250 -9 41 0
(866) 632-9992 or (800) 877-833e (T1'Y)
Or complete the USDA Prograrn Discrimination Complaint Form, found online at
http://www.ascr.usda.gov/compbilllE1ing cust.html.
lndividuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the
Federal Relay Service at (800) 877-8339; or (800) 845-6136 (in Spanish). USDA is an equal
opportunity provider and employer.
USDA is an equal opportunity provider and employer.
Income Guidelines
HOUSEHOLD
SIZE
YEARLY
MONTHLY
TWICE PER
MONTH
EVERY TWO
WEEKS
WEEKLY
I
21,257
1,712
886
818
2
28,694
I,196
I,104
J
1,506
1,390
409
552
69s
4
5
36,131
43,568
51,005
2,392
3,0t I
3,631
1,816
|,676
E38
4,251
6
58,442
4,8'71
2,126
2,436
7
65,879
73.3t 6
5,490
2,7 45
3.055
1,962
2,248
2,534
2.820
|,267
l.,l t 0
+310
+287
+144
8
For each
Household
mcmber add:
Sent
ced-Price meals - 18570) Effecti ve July I. 2013-June 30.2014
+1,4J7
To: Media Outlets
6
0
+620
Date: /
Routing: Submit original to media outlet and one copy to
/
981
|,124
(mm/
State Agency. Retain one copy for your files. (12l13)
Handout ll4b
Summer Food Service Program- MEDIA RELEASE,
-
Site Address and Phone
Name of Site
Contact Person
Number
Camps and Closed Enrolled Sites
Start Date/
End Date
Meal Service
Start Time
Meal Service
f,nd Time
USE ATTACHMENT SHEETS IF NECESSARY
Routing: Submit original to media outlet and one copy to
State Agency. Retain one copy for your liles. ( l2l13 )
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North Carolina
Department of Health and Human Services
Division of Public Health
Nutrition Services Branch
Special Nutrition Program
Complaint Form
Date of Complaint:
Handout
#8
Sponsor Number:
Name and address of Institution.
Is this a Civil Rights Complaint: ( ) Yes ( ) No. If "Yes," please indicate the type of
Civil Right Complaint:
( ) Race ( ) Sex ( )Color ( )Age ( ) National Origin ( ) Disability;
and give the date the civil right complaint was sent to the Food and Nutrition
Services
please state the nature of the complaint below:
Nature of Complaint:
Result of lnvestigation:
ls further Investigation Warranted? If "Yes," explain.
(
) Yes
(
) No
Investigator's Signature:
Date:
Unit Manager's Signature:
Date:
DHHS-CAC Complaint
Nutrition Services
(
I
/12)
Handout
Multiple Webinar Participants Sign-ln
Special Nutrition Programs Civil Rights Training
Date
Sponsor Name:
Agreement Number:
Cou
By
the end of this session, participants will be able to:
1. Apply civil rights requirements and policies as they relate to the
Special N utrition Programs;
2. Describe the responsibilities, requirements, and procedures
necessary to ensure compliance at the federal, state and local
leve ls;
3. ldentify minimum program requirements to ensure compliance;
4, Explain the Civil Rights Policy for the Special Nutrition programs
outlined in FNS lnstruction 113-1.
Print Name
Signature
1.
2.
3.
5.
6.
7.
8.
9.
10.
Keep on tile:
Make a certificate for all attendees:
Only submit one certificate with your SNP application.
as
#9
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