NSW Healthy School Canteen | Your Assessment & Menu Check Application Form | Page 1
MENUCHECK
APPLICATION FORM
NSW Healthy School Canteen Strategy
Page 2 | NSW Healthy School Canteen | Menu Check Application Form
The NSW Healthy School Canteen Menu Check Service can help you check if your canteen menu meets the NSW Healthy School Canteen Strategy Food and Drink Criteria. Your school can use this application form to submit a request for a voluntary school canteen menu check.
Support for Schools to submit an application
Primary and central or K-10/12 schools participating in Live Life Well @ School can access support from the local health promotion officer. See the NSW Healthy Kids website for contact details: www.healthykids.nsw.gov.au/campaigns-programs/nsw-healthy-school-canteen-strategy.aspx
Secondary schools can access support by calling the NSW School Canteen Secondary School Support Service: Phone: (02) 9876 1300 (TOLL FREE)
For any questions about the NSW School Canteen Menu Check Service please contact:
Phone: 02 9133 8711 (TOLL FREE) Email: [email protected] Fax: (02) 9133 8719
MENU CHECK APPLICATI0N F0RM
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 3
School Name:
Principal’s Name: OfficeNumber:
EmailAddress:
SchoolAddress:
Suburb: Postcode:
Canteen Manager:
Besttimesanddaystocontact:
EmailAddress: Phone/MobileNumber:
Live Life Well @ School Contact (where applicable):
EmailAddress: Phone/MobileNumber:
SchoolSector: GOVERNMENT CATHOLIC INDEPENDENT
SchoolType: PRIMARY SECONDARY OTHER (Please specify)
IgivepermissiontocontacttheCanteenManagerdirectlyaboutthisapplication,andunderstandthatthefeedbackwe receivewillbesenttome,asprincipal.
Ifadditionalinformationisrequiredtocompletetheassessment,thebestdayandtimetocontactme/usis:
SchoolCanteentype:
SCHOOLOPERATEDLICENSEDCONTRACTORP&C/P&FOTHER (Please specify)
Numberofdaysperweekyourcanteenoperates:
12345OTHER (Please specify)
Inadditiontofillingoutthisapplicationform,I/wehave:
Attachedacopyofourcurrentcanteenmenu.
Circleditemsontheattachedmenuthatarefreshlypreparedonsite(canteenmade).
Listedallflavoursavailable(whennotspecifiedonthemenu).
Note:TheinformationgatheredandreportedaspartoftheSchoolCanteenMenuAssessmentServicewillbeprovidedtotherelevanteducationsector–NSWDepartmentofEducation,NSWCatholicSchoolsortheAssociationofIndependentSchoolsofNSW.
Primary and Central or K-10/12 schools
IgivepermissionfortheinformationprovidedtotheSchoolCanteenMenuCheckService(Application,menucheckresultsandreport(s))tobesharedwiththerelevantLocalHealthDistrictHealthPromotionservicesthatprovidesupporttoprimaryschoolsparticipatinginLiveLifeWell@School.
Principal’s Signature: Dated:
Pleasesendcompletedformsandattachmentstomenucheck@nswhealthyschoolcanteens.com.au
APPLICATION
OFFICE USE ONLY
DateReceived: LHD:
DateEntered:
Page 4 | NSW Healthy School Canteen Strategy | Menu Check Application Form
HOW TO COMPLETE THIS FORM
Please follow the instructions in the tables and questions. And be sure to list all flavours or types of menu items that are available in your canteen.
Whencompletingthetablespleasecircleanyfoodordrinksonyourmenuthatare‘CanteenMade’.‘CanteenMade’meansanyfoodsordrinksthatarepreparedorcookedonsitefromacombinationofingredients.Forexample:
Pie $3.00
Sausage Roll $2.00
Macaroni Cheese $3.00
Lasagne $3.50
Juice (250mL) $2.50
Flavoured Milk (300mL) $3.00
Bottled Water $2.00
Pleasewritetheflavoursnexttothemenuitemifthey’renotalreadylistedonthemenu.Eachflavourofanitemiscountedseparately.Itisimportantthatyourmenulistsallflavoursthatareavailable.Forexample:
Seeexamplebelowtohelpcompletetheproductinformationtables:
Apple, Orange
ITEM NAME (as listed on Canteen Menu)
BRAND NAME (or indicate if Canteen Made)
PRODUCT NAME
Mrs Smith’s Pizza Canteen Made Ham & Pineapple Pizza
ITEM NAME: Thenameofthefoodordrinkaslistedonyourmenu.
BRAND NAME Themanufacturer’sname.Iffreshlypreparedor (or indicate if madeonsite(inthecanteen),pleasewrite CANTEEN MADE): “CANTEENMADE”inbrandnamecolumn.
PRODUCT NAME: Thenameoftheitemaswrittenonthepackaging.
PACKAGED: Commerciallymadeproducts.
MEAL DEAL: Whentwoormorefoodsarebundledtogetherfora reducedpriceorpromotion,forexample:asandwich withawaterorjuice;acoffeewithamueslibar.
SPECIAL: Anypromoteditemincludingspecialpriceor availability;forexample,onlyavailableoncertain daysoftheweek.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 5
SCHOOL CANTEEN MENU INFORMATION
1.1 Pizzas
1.3 Popcorn
1.2 Are chicken burgers or veggie burgers available in your canteen?
YES NO
IfYES,isthechickenpattycrumbed?
YES NO
IfYES,istheveggiepattycrumbed?
YES NO
Pleasecompleteallsectionsthatarerelevanttothefoodsanddrinkssoldatyourcanteen.
TABLE 1.1
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
FLAVOUR / TYPE OFFICE USE ONLY
TABLE 1.3
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
FLAVOUR / TYPE OFFICE USE ONLY
NOTE: Canteen made pizza includes those made on site (within the canteen) on either commercial or canteen made bases. If you run out of room in the table, please use the blank table on Page 22.
If you run out of room in the table, please use the blank table on Page 22.
Page 6 | NSW Healthy School Canteen Strategy | Menu Check Application Form
1.4 Freshly prepared on site sweet items – cakes, biscuits, slices, pastries, (excluding muffins and fruit breads)
TABLE 1.4
ITEM NAME (as appears on Canteen Menu)
INGREDIENTS (please list the ingredients used to make the canteen made item)
OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 7
If you run out of room in the table, please use the blank table on Page 22.
2.1 Ice creams, frozen snacks, including ice-blocks, or desserts (e.g. mousse)
TABLE 2.1
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
OFFICE USE ONLY
Page 8 | NSW Healthy School Canteen Strategy | Menu Check Application Form
2.2 Packaged (commercially made) muesli bars or snack bars
TABLE 2.2
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 9
3.1 Salty snacks, such as chips, soy crisps, flavoured rice snacks or crackers, noodle snacks, pretzels, legume snacks
TABLE 3.1
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
SERVING SIZE
(grams)
OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
Page 10 | NSW Healthy School Canteen Strategy | Menu Check Application Form
3.2 Pies including meat, vegetable and potato top
TABLE 3.2
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
SERVING SIZE
(grams)
OFFICE USE ONLY
NOTE: If pies are made by your local bakery, please list bakery name and suburb in the “Brand Name” column. If you run out of room in the table, please use the blank table on Page 22.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 11
3.3 Muffins or fruit bread / loaf, such as banana bread
TABLE 3.3
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
SERVING SIZE
(grams)
OFFICE USE ONLY
NOTE: If canteen made muffins or fruit bread/loaf, please leave serving size blank and complete the relevant tables below. If you run out of room in the table, please use the blank table on Page 22.
Page 12 | NSW Healthy School Canteen Strategy | Menu Check Application Form
List freshly prepared on site (canteen made) muffins in Table 3.3a below
3.3a Freshlypreparedonsite(canteenmade)muffins
TABLE 3.3a
ITEM NAME (as appears on Canteen Menu)
INGREDIENTS (please list the ingredients used to
make the canteen made item)
SERVING SIZE (Please tick the serve size as sold)
OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 13
If you run out of room in the table, please use the blank table on Page 22.
IfFRESHLYPREPAREDONSITE(CANTEEN MADE) FRUIT BREAD/LOAF arelistedinthetablebelow(TABLE3.3b)
3.3b Freshly prepared (canteen made) fruit bread/loaf
TABLE 3.3b
ITEM NAME (as appears on Canteen Menu)
INGREDIENTS (please list the ingredients used to
make the canteen made item)
SERVING SIZE (Please tell us the approximate
cake tin size and number of serves you get from one cake tin.)
OFFICE USE ONLY
Page 14 | NSW Healthy School Canteen Strategy | Menu Check Application Form
3.4 Fruit and/or vegetable juices
TABLE 3.4
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
SERVING SIZE (mLs)
OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 15
3.5 Flavoured milks, including breakfast drinks, smoothies, milkshakes, and thickshakes
TABLE 3.5
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
SERVING SIZE (mLs)
OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
Page 16 | NSW Healthy School Canteen Strategy | Menu Check Application Form
4.1 Meal deals (a meal deal is any foods or drinks bundled together as a promotion or for a special price)
TABLE 4.1
MEAL DEAL NAME WHAT IS INCLUDED IN THE MEAL DEAL? (Please list items, including brand name and product name if possible)
OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 17
If you run out of room in the table, please use the blank table on Page 22.
4.2 Does your canteen have a specials board?
YES NO
4.3 Does your canteen offer any specials? (specials include any item promoted by special pricing or special availability, such as only available on certain days, or meal deals, for example)
YES NO
Please list any specials in the table below.
TABLE 4.3
ITEM INCLUDED IN SPECIALS
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
OFFICE USE ONLY
Page 18 | NSW Healthy School Canteen Strategy | Menu Check Application Form
4.4 In the table below, please tell us about pictures of foods, drinks, or brand names/logo that appear on your fridges or freezers that can be seen by students at the counter
TABLE 4.4
Description of foods/drinks and brand names/logos ON FRIDGES or FREEZERS OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 19
4.5 Does your counter have food and drinks that are placed on the countertop or at the front of the canteen service area?
YES NO
4.6 In the table below, please list all foods and drinks that are placed on the countertop or at the front of the canteen service area during RECESS.
TABLE 4.6
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
Page 20 | NSW Healthy School Canteen Strategy | Menu Check Application Form
4.7 In the table below, please list all foods and drinks that are placed on the countertop or at the front of the canteen service area during LUNCH.
TABLE 4.7
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR OFFICE USE ONLY
If you run out of room in the table, please use the blank table on Page 22.
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 21
If you run out of room in the table, please use the blank table on Page 22.
5.1 Cold drinks, other than bottled water, milk (including flavoured), or 99% juice
TABLE 5.1
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or FLAVOUR
OFFICE USE ONLY
Thank you for taking the time to complete the application form. This helps us to check your menu. Please finish your application by signing Page 3. Please send completed applications to:
Email: [email protected] • Fax: (02) 9133 8719
Page 22 | NSW Healthy School Canteen Strategy | Menu Check Application Form
Use this table if you have run out of room in the other tables.Please don’t forget to include the number of the question you are answering in the left hand column of this table.
EXTRA TABLE
QUESTION NUMBER
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or
FLAVOUR
SERVING SIZE (mLs)
OFFICE USE
ONLY
NSW Healthy School Canteen Strategy | Menu Check Application Form | Page 23
Use this table if you have run out of room in the other tables.Please don’t forget to include the number of the question you are answering in the left hand column of this table.
EXTRA TABLE
QUESTION NUMBER
ITEM NAME (as appears on Canteen Menu)
BRAND NAME (or indicate if CANTEEN MADE)
PRODUCT NAME and/or
FLAVOUR
SERVING SIZE (mLs)
OFFICE USE
ONLY