nsw healthy school canteen your assessment & menu ......3.1 salty snacks, such as chips, soy...

NSW Healthy School Canteen | Your Assessment & Menu Check Application Form |

MENUCHECK

APPLICATION FORM

NSW Healthy School Canteen Strategy

| 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

http://www.healthykids.nsw.gov.au/campaigns-programs/nsw-healthy-school-canteen-strategy.aspx

http://www.healthykids.nsw.gov.au/campaigns-programs/nsw-healthy-school-canteen-strategy.aspx

mailto:menucheck%40nswhealthyschoolcanteens.com.au?subject=

NSW Healthy School Canteen Strategy | Menu Check Application Form |

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:

mailto:menucheck%40nswhealthyschoolcanteens.com.au?subject=

| 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.


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



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.


1.4 Freshly prepared on site sweet items – cakes, biscuits, slices, pastries, (excluding muffins and fruit breads)

TABLE 1.4


INGREDIENTS (please list the ingredients used to make the canteen made item)

OFFICE USE ONLY




2.1 Ice creams, frozen snacks, including ice-blocks, or desserts (e.g. mousse)

TABLE 2.1



PRODUCT NAME and/or FLAVOUR

OFFICE USE ONLY


2.2 Packaged (commercially made) muesli bars or snack bars

TABLE 2.2




OFFICE USE ONLY



3.1 Salty snacks, such as chips, soy crisps, flavoured rice snacks or crackers, noodle snacks, pretzels, legume snacks

TABLE 3.1




SERVING SIZE

(grams)

OFFICE USE ONLY



3.2 Pies including meat, vegetable and potato top

TABLE 3.2




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.


3.3 Muffins or fruit bread / loaf, such as banana bread

TABLE 3.3




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.


List freshly prepared on site (canteen made) muffins in Table 3.3a below

3.3a Freshlypreparedonsite(canteenmade)muffins

TABLE 3.3a


INGREDIENTS (please list the ingredients used to

make the canteen made item)

SERVING SIZE (Please tick the serve size as sold)

OFFICE USE ONLY




IfFRESHLYPREPAREDONSITE(CANTEEN MADE) FRUIT BREAD/LOAF arelistedinthetablebelow(TABLE3.3b)

3.3b Freshly prepared (canteen made) fruit bread/loaf

TABLE 3.3b


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


3.4 Fruit and/or vegetable juices

TABLE 3.4




SERVING SIZE (mLs)

OFFICE USE ONLY



3.5 Flavoured milks, including breakfast drinks, smoothies, milkshakes, and thickshakes

TABLE 3.5




SERVING SIZE (mLs)

OFFICE USE ONLY



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




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



OFFICE USE ONLY


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



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


PRODUCT NAME and/or FLAVOUR OFFICE USE ONLY



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


PRODUCT NAME and/or FLAVOUR OFFICE USE ONLY




5.1 Cold drinks, other than bottled water, milk (including flavoured), or 99% juice

TABLE 5.1




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


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



PRODUCT NAME and/or

FLAVOUR

SERVING SIZE (mLs)

OFFICE USE

ONLY

nsw healthy school canteen your assessment & menu ......3.1 salty snacks, such as chips, soy...

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