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NSW Healthy School Canteen Your Assessment & Menu Check Application Form Page 1MENUCHECKNSW Healthy School Canteen StrategyAPPLICATION FORM

Page 2 NSW Healthy School Canteen Menu Check Application FormMENU CHECKAPPLICATI0N F0RMThe NSW Healthy School Canteen Menu Check Service can help youcheck if your canteen menu meets the NSW Healthy School CanteenStrategy Food and Drink Criteria. Your school can use this applicationform to submit a request for a voluntary school canteen menu check.Support for Schools to submit an applicationPrimary and central or K-10/12 schools participatingin Live Life Well @ School can access support from thelocal health promotion officer. See the NSW Healthy Kidswebsite for contact ry schools can access support by callingthe NSW School Canteen Secondary School Support Service:Phone: (02) 9876 1300 (TOLL FREE)For any questions about the NSW School CanteenMenu Check Service please contact:Phone: 02 9133 8711 (TOLL FREE)Email: menucheck@nswhealthyschoolcanteens.com.auFax: (02) 9133 8719

NSW Healthy School Canteen Strategy Menu Check Application Form Page 3APPLICATIONSchool Name:Office Number:Principal’s Name:Email Address:School Address:Suburb:Postcode:Canteen Manager:Best times and days to contact:Email Address:Phone/Mobile Number:Live Life Well @ School Contact (where applicable):Email Address:School Sector:Phone/Mobile Number:GOVERNMENTCATHOLICSchool Type:PRIMARYSECONDARYINDEPENDENTOTHER(Please specify)I give permission to contact the Canteen Manager directly about this application, and understand that the feedback wereceive will be sent to me, as principal.If additional information is required to complete the assessment, the best day and time to contact me/us is:School Canteen type:SCHOOL OPERATED LICENSED CONTRACTOR P&C / P&F OTHER(Please specify)Number of days per week your canteen operates:1 2 3 4 5 OTHER(Please specify)In addition to filling out this application form, I/we have:Attached a copy of our current canteen menu.Circled items on the attached menu that are freshly prepared on site (canteen made).Listed all flavours available (when not specified on the menu).Note: The information gathered and reported as part of the School Canteen Menu Assessment Service will be provided to the relevant educationsector – NSW Department of Education, NSW Catholic Schools or the Association of Independent Schools of NSW.Primary and Central or K-10/12 schoolsI give permission for the information provided to the School Canteen Menu Check Service (Application, menu check resultsand report(s)) to be shared with the relevant Local Health District Health Promotion services that provide support to primaryschools participating in Live Life Well @ School.Principal’s Signature:Dated:Please send completed forms and attachments to menucheck@nswhealthyschoolcanteens.com.auOFFICE USE ONLYDate Received:Date Entered:LHD:

Page 4 NSW Healthy School Canteen Strategy Menu Check Application FormHOW TO COMPLETE THIS FORMPlease follow the instructions inthe tables and questions. And besure to list all flavours or types ofmenu items that are available inyour canteen.When completing the tables please circle any food or drinks on your menuthat are ‘Canteen Made’. ‘Canteen Made’ means any foods or drinks that areprepared or cooked on site from a combination of ingredients. For example:Pie 3.00Sausage Roll 2.00Macaroni Cheese 3.00Lasagne 3.50Please write the flavours next to the menu item if they’re not already listedon the menu. Each flavour of an item is counted separately. It is importantthat your menu lists all flavours that are available. For example:Apple, OrangeJuice (250mL) 2.50Flavoured Milk (300mL) 3.00Bottled Water 2.00See example below to help complete the product information tables:ITEM NAMEBRAND NAME(as listed on Canteen Menu)(or indicate if Canteen Made)Mrs Smith’s PizzaCanteen MadePRODUCT NAMEHam & Pineapple PizzaITEM NAME:The name of the food or drink as listed on your menu.BRAND NAME(or indicate ifCANTEEN MADE):The manufacturer’s name. If freshly prepared ormade on site (in the canteen), please write“CANTEEN MADE” in brand name column.PRODUCT NAME:The name of the item as written on the packaging.PACKAGED:Commercially made products.MEAL DEAL:When two or more foods are bundled together for areduced price or promotion, for example: a sandwichwith a water or juice; a coffee with a muesli bar.SPECIAL:Any promoted item including special price oravailability; for example, only available on certaindays of the week.

NSW Healthy School Canteen Strategy Menu Check Application Form Page 5SCHOOL CANTEEN MENU INFORMATIONPlease complete all sections that are relevant to the foods and drinks sold at your canteen.1.1 PizzasTABLE 1.1ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)FLAVOUR / TYPEOFFICE USEONLYNOTE: Canteen made pizza includes those made on site (within the canteen) on either commercial or canteen madebases. If you run out of room in the table, please use the blank table on Page 22.1.2 Are chicken burgers or veggie burgers available in your canteen?YESNOIf YES, is the chicken patty crumbed?YESNOIf YES, is the veggie patty crumbed?YESNO1.3 PopcornTABLE 1.3ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)If you run out of room in the table, please use the blank table on Page 22.FLAVOUR / TYPEOFFICE USEONLY

Page 6 NSW Healthy School Canteen Strategy Menu Check Application Form1.4 Freshly prepared on site sweet items – cakes, biscuits, slices, pastries, (excluding muffins and fruit breads)TABLE 1.4ITEM NAME(as appears onCanteen Menu)INGREDIENTS(please list the ingredients used to make the canteen made item)If you run out of room in the table, please use the blank table on Page 22.OFFICE USEONLY

NSW Healthy School Canteen Strategy Menu Check Application Form Page 72.1 Ice creams, frozen snacks, including ice-blocks, or desserts (e.g. mousse)TABLE 2.1ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)If you run out of room in the table, please use the blank table on Page 22.PRODUCT NAMEand/or FLAVOUROFFICE USEONLY

Page 8 NSW Healthy School Canteen Strategy Menu Check Application Form2.2 Packaged (commercially made) muesli bars or snack barsTABLE 2.2ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)If you run out of room in the table, please use the blank table on Page 22.PRODUCT NAMEand/or FLAVOUROFFICE USEONLY

NSW Healthy School Canteen Strategy Menu Check Application Form Page 93.1 Salty snacks, such as chips, soy crisps, flavoured rice snacks or crackers, noodle snacks, pretzels,legume snacksTABLE 3.1ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)PRODUCT NAMEand/or FLAVOURIf you run out of room in the table, please use the blank table on Page 22.SERVINGSIZE(grams)OFFICE USEONLY

Page 10 NSW Healthy School Canteen Strategy Menu Check Application Form3.2 Pies including meat, vegetable and potato topTABLE 3.2ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)PRODUCT NAMEand/or FLAVOURSERVINGSIZE(grams)OFFICE USEONLYNOTE: 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 113.3 Muffins or fruit bread / loaf, such as banana breadTABLE 3.3ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)PRODUCT NAMEand/or FLAVOURSERVINGSIZE(grams)OFFICE USEONLYNOTE: If canteen made muffins or fruit bread/loaf, please leave serving size blank and complete the relevant tablesbelow. 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 FormList freshly prepared on site (canteen made) muffins in Table 3.3a below3.3a Freshly prepared on site (canteen made) muffinsTABLE 3.3aITEM NAMEINGREDIENTS(as appears onCanteen Menu)(please list the ingredients used tomake the canteen made item)SERVING SIZE(Please tick the serve size as sold)If you run out of room in the table, please use the blank table on Page 22.OFFICE USEONLY

NSW Healthy School Canteen Strategy Menu Check Application Form Page 13If FRESHLY PREPARED ON SITE (CANTEEN MADE) FRUIT BREAD/LOAF are listed in the table below (TABLE 3.3b)3.3b Freshly prepared (canteen made) fruit bread/loafTABLE 3.3bITEM NAMEINGREDIENTS(as appears onCanteen Menu)(please list the ingredients used tomake the canteen made item)SERVING SIZE(Please tell us the approximatecake tin size and number of servesyou get from one cake tin.)If you run out of room in the table, please use the blank table on Page 22.OFFICE USEONLY

Page 14 NSW Healthy School Canteen Strategy Menu Check Application Form3.4 Fruit and/or vegetable juicesTABLE 3.4ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)PRODUCT NAMEand/or FLAVOURIf you run out of room in the table, please use the blank table on Page 22.SERVINGSIZE(mLs)OFFICE USEONLY

NSW Healthy School Canteen Strategy Menu Check Application Form Page 153.5 Flavoured milks, including breakfast drinks, smoothies, milkshakes, and thickshakesTABLE 3.5ITEM NAMEBRAND NAME(as appears on Canteen Menu)(or indicate if CANTEEN MADE)PRODUCT NAMEand/or FLAVOURIf you run out of room in the table, please use the blank table on Page 22.SERVINGSIZE(mLs)OFFICE USEONLY

Page 16 NSW Healthy School Canteen Strategy Menu Check Application Form4.1 Meal deals (a meal deal is any foods or drinks bundled together as a promotion or for a special price)TABLE 4.1MEAL DEAL NAMEWHAT IS INCLUDED IN THE MEAL DEAL?(Please list items, including brand name and product name if possible)If you run out of room in the table, please use the blank table on Page 22.OFFICE USEONLY

NSW Healthy School Canteen Strategy Menu Check Application Form Page 174.2 Does your canteen have a specials board?YESNO4.3 Does your canteen offer any specials? (specials include any item promoted by special pricing orspecial availability, such as only available on certain days, or meal deals, for example)YESNOPlease list any specials in the table below.TABLE 4.3ITEM INCLUDEDIN SPECIALSBRAND NAME(or indicate if CANTEEN MADE)If you run out of room in the table, please use the blank table on Page 22.PRODUCT NAMEand/or FLAVOUROFFICE USEONLY

Page 18 NSW Healthy School Canteen Strategy Menu Check Application Form4.4 In the table below, please tell us about pictures of foods, drinks, or brand names/logo that appearon your fridges or freezers that can be seen by students at the counterTABLE 4.4Description of foods/drinks and brand names/logos ON FRIDGES or FREEZERSIf you run out of room in the table, please use the blank table on Page 22.OFFICE USEONLY

NSW Healthy School Canteen Strategy Menu Check Application Form Page 194.5 Does your counter have food and drinks that are placed on the countertop or at the front of thecanteen service area?YESNO4.6 In the table below, please list all foods and drinks that are placed on the countertop or at the front ofthe canteen service area during RECESS.TABLE 4.6BRAND NAME(or indicate if CANTEEN MADE)PRODUCT NAME and/or FLAVOURIf you run out of room in the table, please use the blank table on Page 22.OFFICE USEONLY

Page 20 NSW Healthy School Canteen Strategy Menu Check Application Form4.7 In the table below, please list all foods and drinks that are placed on the countertop or at the frontof the canteen service area during LUNCH.TABLE 4.7BRAND NAME(or indicate if CANTEEN MADE)PRODUCT NAME and/or FLAVOURIf you run out of room in the table, please use the blank table on Page 22.OFFICE USEONLY