Breakfast Brigade Reporting Form

Please fill in the following information about the person with whom you have been in contact to conduct Breakfast Brigade work.

1. Breakfast Brigade Member Name: * First Last
Your Email Address *
2. Contact person's name: First Last
3. Contact person's title:
4. School/School District:
5. Phone: - (###) - ### ####
6. Contact person's email:
7. Which of the following describes his/her school breakfast goal? (Check one) He/She wants to improve participation in an existing school breakfast program. (Go to Question 8.) He/She wants to start a new school breakfast program. (Go to Question 9.)
8. What is the current ADP for breakfast at the targeted school?
9. Name(s) of the targeted school(s):
10. Grade level(s) of the targeted school(s): Elementary Middle School Junior High Junior/Senior High High School
Please describe your contact(s) with this person.
11. Describe the nature and date(s) of the contact(s). (For example, did you visit his/her school, did he/she visit your school, etc.)
12. Describe what took place during your contact(s).
13. Describe follow-up plans.
14. Other information you would like to provide:
15. Please document travel expenses:
Itinerary - From:
Itinerary - To:
Estimated round trip mileage: (You will be reimbursed at Penn State's standard rates.)
Date of trip: / MM / DD YYYY
Meals: (You will be reimbursed at Penn State's standard rates.)
Other expenses (hotels, tolls, parking, etc.). Please send receipts.