Child and Adult Care Food Program ADULT CARE CENTER—ATTENDANCE ROSTER Study Month _________ Use this form to prepare an attendance roster. Use one roster per site. Summarize on the Study Month Summary form. Each proprietary site must meet Title XIX eligibility in order to be claimed. Name of Institution: Name of Site: Claiming Categories OSPI Name of Eligible Adult in Attendance Age of Type of Case Number/ Verification Source Eligibility Begin Use Only Reduced- Above- and Last Name—Alphabetize by Last Name) Person Assistance Date/ End Date Free NO. Price Scale 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Medicaid, SSI = Supplemental Security Income, Basic Food, FDPIR Reduced- Free Above- Type of Assistance: Total (this page) Price = Food Distribution Program on Indian Reservations Scale =
Child and Adult Care Food Program ADULT CARE CENTER—ATTENDANCE ROSTER Study Month _________ Use this form to prepare an attendance roster. Use one roster per site. Summarize on the Study Month Summary form. Each proprietary site must meet Title XIX eligibility in order to be claimed. Name of Institution: Name of Site: NO. Name of Eligible Adult in Attendance and Last Name—Alphabetize by Last Name) Age of Person Type of Assistance Case Number/ Verification Source Eligibility Begin Date/ End Date Claiming Categories OSPI Use Only Free Reduced- Price Above- Scale 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Type of Assistance: Medicaid, SSI = Supplemental Security Income, Basic Food, FDPIR = Food Distribution Program on Indian Reservations Reduced- Free Price Above- Scale Total (this page) =
AttendanceRosterAdultCare.docx