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.

+--------------------------------+-------------------------------------+
| Manufacturer Name: (Max 30     | Date Submitted: (MM/DD/YYYY)        |
| characters)                    |                                     |
+--------------------------------+-------------------------------------+
| Contact Name and Address:      | Product Number:                     |
+--------------------------------+-------------------------------------+
| MFR Product Name: (Max 76      | Product Name Shortened:             |
| characters)                    |                                     |
+--------------------------------+-------------------------------------+
| Brand: (Max 40 characters)     | Unit UPC: (12 numbers)              |
+--------------------------------+-------------------------------------+
| CNP Food Category:             | Product is Produced Specifically    |
|                                | for Child Nutrition Program?        |
|                                |                                     |
|                                | YES NO                              |
+--------------------------------+-------------------------------------+
| NLEA Adjusted Values: YES NO   |                                     |
| Analytical (A), USDA Data (U), |                                     |
| Calculated (C)                 |                                     |
|                                |                                     |
| A U C                          |                                     |
+--------------------------------+-------------------------------------+
| As Consumed (C) or As          |                                     |
| Purchased (P): C P             |                                     |
+--------------------------------+-------------------------------------+
| Is this an enriched or         |                                     |
| fortified product? YES NO      |                                     |
+--------------------------------+-------------------------------------+

LIST OF INGREDIENTS:

+-----------------------------------+---+-------------------------------+
| Product Number:                   |   | Serving Size For Nutrients:   |
|                                   |   | (Grams)                       |
+-----------------------------------+---+-------------------------------+
| Household Serving Size:           |   | Household Serving Measure:    |
+-----------------------------------+---+-------------------------------+
| Household Serving Description:    |   |                               |
+-----------------------------------+---+-------------------------------+
| Energy: Calories: KCal (Calories) | > |                               |
|                                   |   |                               |
| Total Fat (lipid): g              | P |                               |
|                                   | r |                               |
| Saturated Fat: g                  | o |                               |
|                                   | t |                               |
| Water (Moisture): g               | e |                               |
|                                   | i |                               |
| Ash: g                            | n |                               |
|                                   | > |                               |
| Carbohydrates (Total): g          |   |                               |
|                                   | ( |                               |
| Cholesterol: mg                   | T |                               |
|                                   | o |                               |
| Total Dietary Fiber: g            | t |                               |
|                                   | a |                               |
| Trans Fat: g                      | l |                               |
|                                   | ) |                               |
|                                   | : |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | g |                               |
|                                   | > |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | S |                               |
|                                   | o |                               |
|                                   | d |                               |
|                                   | i |                               |
|                                   | u |                               |
|                                   | m |                               |
|                                   | : |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | m |                               |
|                                   | g |                               |
|                                   | > |                               |
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|                                   |   |                               |
|                                   | V |                               |
|                                   | i |                               |
|                                   | t |                               |
|                                   | a |                               |
|                                   | m |                               |
|                                   | i |                               |
|                                   | n |                               |
|                                   | > |                               |
|                                   |   |                               |
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|                                   | : |                               |
|                                   | > |                               |
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|                                   | I |                               |
|                                   | U |                               |
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|                                   | V |                               |
|                                   | i |                               |
|                                   | t |                               |
|                                   | a |                               |
|                                   | m |                               |
|                                   | i |                               |
|                                   | n |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | A |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | ( |                               |
|                                   | R |                               |
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|                                   | t |                               |
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|                                   | V |                               |
|                                   | i |                               |
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|                                   | m |                               |
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|                                   | > |                               |
|                                   |   |                               |
|                                   | C |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | ( |                               |
|                                   | T |                               |
|                                   | o |                               |
|                                   | t |                               |
|                                   | a |                               |
|                                   | l |                               |
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|                                   | : |                               |
|                                   | > |                               |
|                                   |   |                               |
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|                                   | g |                               |
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|                                   |   |                               |
|                                   | I |                               |
|                                   | r |                               |
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|                                   | n |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | ( |                               |
|                                   | T |                               |
|                                   | o |                               |
|                                   | t |                               |
|                                   | a |                               |
|                                   | l |                               |
|                                   | ) |                               |
|                                   | : |                               |
|                                   | > |                               |
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|                                   | m |                               |
|                                   | g |                               |
|                                   | > |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | C |                               |
|                                   | a |                               |
|                                   | l |                               |
|                                   | c |                               |
|                                   | i |                               |
|                                   | u |                               |
|                                   | m |                               |
|                                   | : |                               |
|                                   | > |                               |
|                                   |   |                               |
|                                   | m |                               |
|                                   | g |                               |
+-----------------------------------+---+-------------------------------+
| EACH:                             | D |                               |
|                                   | e |                               |
| Unit Quantity:                    | s |                               |
|                                   | c |                               |
| Unit Size:                        | r |                               |
|                                   | i |                               |
| LB                                | p |                               |
|                                   | t |                               |
| IN                                | i |                               |
|                                   | o |                               |
| IN                                | n |                               |
|                                   | : |                               |
| Serving Per Each Unit:            |   |                               |
|                                   | U |                               |
|                                   | n |                               |
|                                   | i |                               |
|                                   | t |                               |
|                                   | S |                               |
|                                   | i |                               |
|                                   | z |                               |
|                                   | e |                               |
|                                   | M |                               |
|                                   | e |                               |
|                                   | a |                               |
|                                   | s |                               |
|                                   | u |                               |
|                                   | r |                               |
|                                   | e |                               |
|                                   | : |                               |
|                                   |   |                               |
|                                   | L |                               |
|                                   | B |                               |
|                                   |   |                               |
|                                   | I |                               |
|                                   | N |                               |
|                                   |   |                               |
|                                   | F |                               |
|                                   | T |                               |
+-----------------------------------+---+-------------------------------+