Programmatic Application for New Contractors



Complete the chart below and submit attachments as indicated. This information will be used to evaluate and compare ingredients, quality, and portion sizes.Agency Name: FORMTEXT ????? Date: FORMTEXT ?????List all food service suppliers for your establishment (i.e. Gordons, Sysco, US foods): FORMTEXT ?????PRODUCT SPECIFICATION NUTRITION INFORMATIONProtein Specifications Protein Specifications Ground Beef, Bulk: FORMCHECKBOX 70/30, FORMCHECKBOX 80/20, FORMCHECKBOX 85/15 FORMCHECKBOX Other (specify) FORMTEXT ?????Pre-Cooked Hamburger Patty: FORMTEXT ????? oz/ea FORMTEXT ????? gm Protein, FORMTEXT ????? gm Fat, FORMTEXT ????? mg NA(sodium)Pre-Cooked Chicken Patty: FORMTEXT ????? oz/ea FORMTEXT ????? gm Protein, FORMTEXT ????? gm Fat, FORMTEXT ????? mg NA(sodium)Boneless Skinless Chicken Breast: FORMTEXT ????? oz/ea FORMTEXT ????? gm Protein, FORMTEXT ????? gm Fat, FORMTEXT ????? mg NA(sodium)Turkey Breast FORMTEXT ????? oz/ea FORMTEXT ????? gm Protein, FORMTEXT ????? gm Fat, FORMTEXT ????? mg NA(sodium)Pork Loin FORMTEXT ????? oz/ea FORMTEXT ????? gm Protein, FORMTEXT ????? gm Fat, FORMTEXT ????? mg NA(sodium)Pork Chop (bone-in or boneless): FORMTEXT ????? oz/ea FORMTEXT ????? gm Protein, FORMTEXT ????? gm Fat, FORMTEXT ????? mg NA(sodium)Ham (bone-in or boneless): FORMTEXT ????? oz/ea FORMTEXT ????? gm Protein, FORMTEXT ????? gm Fat, FORMTEXT ????? mg NA(sodium)DairyDairyMilk: FORMTEXT ????? oz / containerList Variety: FORMTEXT ?????% Fat: FORMTEXT ?????, FORMTEXT ????? gm CarbBrand: FORMTEXT ????? Supplier: FORMTEXT ?????Yogurt: FORMTEXT ????? oz / containerList Variety FORMTEXT ?????% Fat: FORMTEXT ?????, FORMTEXT ????? gm CarbBrand: FORMTEXT ????? Supplier: FORMTEXT ?????FatsFats Margarine or Butter Pads:Size: FORMTEXT ????? gGravy: Dry, canned, or homemade? FORMTEXT ?????List Variety: FORMTEXT ?????Brand: FORMTEXT ?????, FORMTEXT ????? mg NA(sodium) per servingAttach recipe for gravy: canned, dry, and/or scratchVegetables (list a few examples of each)VegetablesFresh: FORMTEXT ?????Supplier (for fresh): FORMTEXT ?????Canned: FORMTEXT ?????Sodium (NA) for canned: FORMTEXT ?????mg per ? cup Frozen: FORMTEXT ?????Sodium (NA) for frozen: FORMTEXT ?????mg per ? cup Mashed Potatoes: Dry, frozen, or scratch? FORMTEXT ?????Attach recipe for mashed potatoesFruits (list a few examples of each)FruitsCanned Fruit: FORMTEXT ?????Pack Type: FORMTEXT ????? (i.e. water, juice, light syrup)Fresh Fruit: FORMTEXT ?????Supplier (for fresh): FORMTEXT ?????Frozen Meals (FM)/EntreesFrozen Meals (FM)/EntreesFM prepped on site? FORMCHECKBOX Yes FORMCHECKBOX NoBrand/Supplier for FM (if purchased): FORMTEXT ????? If purchasing FM from a foodservice supplier, attach a complete nutrition analysis for 3 different mealsAttach a list of purchased frozen food entrees to be consumed after heating (i.e. stuffed peppers, lasagna)Shelf Stable MealsShelf Stable MealsSource/Brand: FORMTEXT ????? Attach a 3-day menu with complete nutrition analysisLiquid MealsLiquid MealsName Brand: FORMTEXT ?????List Products: FORMTEXT ?????NUTRITION ANALYSISBriefly describe method/software program used for menu analysis: FORMTEXT ?????Attach a 1-week sample menu with nutrient analysis. Provide a complete analysis per day and average per week for the following nutrients: calories, protein, carbohydrate, fat, saturated fat, sodium, and dietary fiber. ................
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