MILK USUAGE RECORD - Wisconsin Department of Public ...



Template Special Milk Program Daily Participation Record

Use this form to record the number of half-pints (8 fl. oz or ½ pint equivalents) of milk served to students participating in Special Milk Program (SMP) on the corresponding day. This form must be completed at the time of milk service, when each child receives their milk, also known as the Point of Service (POS). Note, milk served to adults and non-enrolled students cannot be claimed for reimbursement.

• Pricing with Free Milk Option Program: This template is not allowable for this program model as consumption must be tracked by individual student.

• Pricing Program (no free milk): This template may be used for this program model unless the SFA charges individual students by ½ pint (8 fl. oz) consumption.

• Nonpricing Program: This template may be used for this program model.

School/Classroom_______________________________ Month/Year_________ 20__

| |Number of ½ pints (8 fl. oz or ½ pint equivalent) and/or gallons served to enrolled students |Milk served to adults or |

|Date |½ pints |non-enrolled children |

| |Gallons* | |

|1 | | | |

|2 | | | |

|3 | | | |

|4 | | | |

|5 | | | |

|6 | | | |

|7 | | | |

|8 | | | |

|9 | | | |

|10 | | | |

|11 | | | |

|12 | | | |

|13 | | | |

|14 | | | |

|15 | | | |

|16 | | | |

|17 | | | |

|18 | | | |

|19 | | | |

|20 | | | |

|21 | | | |

|22 | | | |

|23 | | | |

|24 | | | |

|25 | | | |

|26 | | | |

|27 | | | |

|28 | | | |

|29 | | | |

|30 | | | |

|31 | | | |

|TOTAL | | | |

*Convert Gallons to ½ Pints: ______Gallons multiplied by (x) 16 = ________ ½ Pints (8 fl oz or ½ pint equivalents)

As a reminder, milk served from gallons must be recorded as used and only milk served to students can be recorded and claimed.

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