U.S. Department of Agriculture • Food and Nutrition Service

**CN Database Qualification Report**

According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a Collection of Information unless it displays a
valid OMB control number. The valid OMB control number for this
information collection is 0584-0494. The time required to complete this
information is estimated to average 120 minutes per response, including
the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection.

+---------------------------------+------------------------------------+
| Date Submitted: (MM/DD/YYYY)    |                                    |
+---------------------------------+------------------------------------+
| Manufacturer Information:       | Manufacturer Information           |
|                                 | Continued:                         |
| Company Name:                   |                                    |
|                                 | Company Website:                   |
| Street1:                        |                                    |
|                                 | Company Phone: (xxx) yyy-zzzz:     |
| Street2:                        |                                    |
|                                 | Company Fax: (xxx) yyy-zzzz:       |
| City, State:                    |                                    |
|                                 | General Email:                     |
| Zip Code:                       |                                    |
+---------------------------------+------------------------------------+
| MFR Product Name: (Max 255      |                                    |
| characters-example: Pizza,      |                                    |
| pepperoni topping, regular      |                                    |
| crust, frozen, cooked)          |                                    |
+---------------------------------+------------------------------------+
| Product Name Shortened:(Max 60  | Brand: (Max 40 characters)         |
| characters-example: pepperoni   |                                    |
| pizza)                          |                                    |
+---------------------------------+------------------------------------+
| Unit UPC: (12 numbers)          | Product Number/Code:               |
|                                 |                                    |
| \_\_ - \_\_ \_\_ \_\_ \_\_      |                                    |
| \_\_ - \_\_ \_\_ \_\_ \_\_      |                                    |
| \_\_ - \_\_                     |                                    |
+---------------------------------+------------------------------------+
| Food Category Code: (from table | Product Is Produced For School     |
| on field explanation page 3)    | Food Service?                      |
|                                 |                                    |
|                                 | YES NO                             |
+---------------------------------+------------------------------------+
| Product Is Produced With USDA   |                                    |
| Commodity Food? YES NO          |                                    |
+---------------------------------+------------------------------------+
| NLEA Adjusted Values: YES NO    |                                    |
|                                 |                                    |
| Value Type Code: Analytical     |                                    |
| Data (A), USDA Data (U),        |                                    |
| Calculated Data (C) A U C       |                                    |
+---------------------------------+------------------------------------+
| As Served (S) or As Purchased   |                                    |
| (P): S P                        |                                    |
|                                 |                                    |
| Is This An Enriched Or          |                                    |
| Fortified Product? YES NO       |                                    |
+---------------------------------+------------------------------------+

Notes:

+-----------------------------------+---+-------------------------------+
| Product Number/Code (from page    |   | Household Serving Amount: (a  |
| one):                             |   | numeric value)                |
+-----------------------------------+---+-------------------------------+
| Household Serving Measure         |   | Household Serving Size In     |
| Description:                      |   | Grams or Ounce:               |
|                                   |   |                               |
| (Example: Cup, Ounce, Patty,      |   | g or oz                       |
| Piece, Slice)                     |   |                               |
+-----------------------------------+---+-------------------------------+
| Nutrient Serving Size (Total Gram |   |                               |
| Weight Of Product Upon Which The  |   |                               |
| Following Nutrients Are Based): g |   |                               |
|                                   |   |                               |
| (Ounce To Gram Conversion Factor: |   |                               |
| Ounce X 28.35g/oz = Grams)        |   |                               |
+-----------------------------------+---+-------------------------------+
| Total Calories: KCal (Calories)   | > |                               |
|                                   |   |                               |
| Total Fat: g                      | V |                               |
|                                   | i |                               |
| Saturated Fat: g                  | t |                               |
|                                   | a |                               |
| \*Trans Fat: g                    | m |                               |
|                                   | i |                               |
| Cholesterol: mg                   | n |                               |
|                                   | > |                               |
| Sodium: mg                        |   |                               |
|                                   | A |                               |
| Total Carbohydrate: g             | : |                               |
|                                   | > |                               |
| Total Dietary Fiber: g            |   |                               |
|                                   | I |                               |
| Protein: g                        | U |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | o |                               |
|                                   | r |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | % |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | D |                               |
|                                   | V |                               |
|                                   | > |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | \ |                               |
|                                   | * |                               |
|                                   | V |                               |
|                                   | i |                               |
|                                   | t |                               |
|                                   | a |                               |
|                                   | m |                               |
|                                   | i |                               |
|                                   | n |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | A |                               |
|                                   | : |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | R |                               |
|                                   | A |                               |
|                                   | E |                               |
|                                   | > |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | V |                               |
|                                   | i |                               |
|                                   | t |                               |
|                                   | a |                               |
|                                   | m |                               |
|                                   | i |                               |
|                                   | n |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | C |                               |
|                                   | : |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | m |                               |
|                                   | g |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | o |                               |
|                                   | r |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | % |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | D |                               |
|                                   | V |                               |
|                                   | > |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | I |                               |
|                                   | r |                               |
|                                   | o |                               |
|                                   | n |                               |
|                                   | : |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | m |                               |
|                                   | g |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | o |                               |
|                                   | r |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | % |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | D |                               |
|                                   | V |                               |
|                                   | > |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | C |                               |
|                                   | a |                               |
|                                   | l |                               |
|                                   | c |                               |
|                                   | i |                               |
|                                   | u |                               |
|                                   | m |                               |
|                                   | : |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | m |                               |
|                                   | g |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | o |                               |
|                                   | r |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | % |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | D |                               |
|                                   | V |                               |
|                                   |   |                               |
|                                   | \ |                               |
|                                   | * |                               |
|                                   | W |                               |
|                                   | a |                               |
|                                   | t |                               |
|                                   | e |                               |
|                                   | r |                               |
|                                   | ( |                               |
|                                   | M |                               |
|                                   | o |                               |
|                                   | i |                               |
|                                   | s |                               |
|                                   | t |                               |
|                                   | u |                               |
|                                   | r |                               |
|                                   | e |                               |
|                                   | ) |                               |
|                                   | : |                               |
|                                   | g |                               |
|                                   |   |                               |
|                                   | \ |                               |
|                                   | * |                               |
|                                   | A |                               |
|                                   | s |                               |
|                                   | h |                               |
|                                   | : |                               |
|                                   | g |                               |
|                                   |   |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | \ |                               |
|                                   | * |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | I |                               |
|                                   | t |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | I |                               |
|                                   | s |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | O |                               |
|                                   | p |                               |
|                                   | t |                               |
|                                   | i |                               |
|                                   | o |                               |
|                                   | n |                               |
|                                   | a |                               |
|                                   | l |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | T |                               |
|                                   | o |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | L |                               |
|                                   | i |                               |
|                                   | s |                               |
|                                   | t |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | V |                               |
|                                   | a |                               |
|                                   | l |                               |
|                                   | u |                               |
|                                   | e |                               |
|                                   | s |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | F |                               |
|                                   | o |                               |
|                                   | r |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | T |                               |
|                                   | h |                               |
|                                   | e |                               |
|                                   | s |                               |
|                                   | e |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | N |                               |
|                                   | u |                               |
|                                   | t |                               |
|                                   | r |                               |
|                                   | i |                               |
|                                   | e |                               |
|                                   | n |                               |
|                                   | t |                               |
|                                   | s |                               |
+-----------------------------------+---+-------------------------------+

LIST OF INGREDIENTS:

Enter the **Date Submitted**, and **Manufacturer Information**. The
**MFR** **Product Name** should follow the naming convention used in the
USDA's National Nutrient Database for Standard Reference
(<http://www.nal.usda.gov/fnic/foodcomp/search/>). The **Product Name
Shortened** should [not]{.underline} be an abbreviation of each word in
the full product name but rather should be a clear and concise shortened
version of the full product name. The **Brand** for the product should
be listed separately from the full or shortened product name. The **Unit
UPC** is the 12 digit Universal Product Code and is important for
correctly matching the information to the product. Example: 0 - 12345 -
12345 -- 0. The **Product Number/Code** should be your product\'s 5
digit UPC \# (The portion after the second dash) if you do not use a
separate product number or code. The **Food Category Code** comes from a
USDA Table. Please select from the following list of 2-digit categories.

**Food Category Codes**

  ---- ------------------------------- ----- ------------------------------
  01   Dairy: butter, cheese, eggs,    16    Condiments: catsup, mustard,
       milk, yogurt                          relish

  02   Spice: seasonings, flavorings,  17    Lamb, veal and game products
       leavening agents                      

  03   Baby food                       18    Baked goods: bread, cakes,
                                             cookies, crackers, pies, rolls

  04   Fats & Oils: margarine,         19    Sweets
       shortening, mayonnaise, salad         
       dressings                             

  05   Poultry Products                20    Grains

  06   Soups, Sauces and Gravies       21    Fast Foods

  07   Luncheon meat & sausage         22    Meals, Entrées, and Side
                                             dishes

  08   Breakfast Cereals               25    Snacks

  09   Fruits and fruit juices         29    Miscellaneous

  10   Pork Products                         

  11   Vegetables: includes beans &    30 -- Reserved for USDA Recipes
       legumes                         39    

  12   Nuts and seeds                        

  13   Beef                            43    Purchased mixed dishes: lunch
                                             entrees

  14   Beverages                       44    Purchased mixed dishes:
                                             breakfast entrees

  15   Fish                            45    Meat substitute/Vegetable
                                             proteins
  ---- ------------------------------- ----- ------------------------------

Indicate whether the product is or is not intended for **School Food
Service** and whether it is or is not produced with **USDA Commodity
Food.** Indicate whether the nutritional information is based on the
**Nutrition Labeling and Education Act (NLEA) Adjusted Values**
(Nutrition Facts data).

Select your **Value Type Code** from the following listing based on the
nutrient data you are reporting:

A - Analytical -laboratory data; U - USDA - from a USDA database; C -
Calculated - from nutrition facts panel or from Individual Ingredients

Indicate whether the nutritional information provided is on an **As
Served** or **As Purchased** basis and whether or not the product is
**Enriched/Fortified**. There is a space for **Notes** if needed.

Repeat the **Product Number/Code** from page one so that page two can be
matched up if necessary.

The **Household Serving Amount** is a numeric value used to describe the
amount of a specific **Household Serving Measure Description**. The two
combined make up the **Household Serving Size.** The **Household Serving
Measure Description** should be chosen from the following list of
abbreviations:

  ----- ----------------------------- --------- ---------------------------------
  CM    Centimeter                    MG        Milligram (1000th of gram;
                                                weight)

  CUP   Cup -- 8 fluid ounces, volume ML        Milliliter (fluid; volume)

  FT    Feet (dimension)              OZ        Ounce (16 ounces = 1 pound;
                                                weight)

  GAL   Gallon (fluid; volume)        FL OZ     Fluid Ounce (8 fluid ounces = 1
                                                cup; volume)

  GM    Gram (weight)                 PACKAGE   Package/Box/Case/Bag

  IN    Inch (12 inch = 1 foot;       PIECE     Piece/Portion/Unit/Item/Serving
        dimension)                              

  KG    Kilogram (1000 grams; weight) PT        Pint, fluid, volume

  LB    Pound (weight)                QT        Quart, fluid, volume (4 quarts =
                                                1 gallon)

  LT    Liter (Fluid; volume)         TBSP      Tablespoon (16 tablespoons = 1
                                                cup; volume)

  M     Meter (dimension)             TSP       Teaspoon (3 teaspoon = 1
                                                tablespoon; volume)
  ----- ----------------------------- --------- ---------------------------------

The **Nutrient Serving Size** in grams may be equivalent to the
**Household Serving Size** or the net weight on a single serve package
if you are reporting Nutrition Facts (NLEA) data. For example, if the
**Nutrient Serving Size** is based on one 57 gram single serve package,
then the **Household Serving Amount** plus the **Household Serving
Measure Description (=Household Serving Size)** would be 2.0 OZ for a
non-liquid product. 57 grams divided by 28.35 grams per ounce equals the
**Household Serving Size** of 2.0 ounces. Provide the nutrient values in
the appropriate units designated in the nutrient list. Nutrients listed
with an asterisk are **Optional**. Lastly, provide a **List of
Ingredients** found in the product by order of predominance.