OREGON DEPARTMENT OF EDUCATIONPage 1 of

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

CACFP CHILD ENROLLMENT ROSTER

(Child Care Centers, Head Start Programs, Outside School Hours Sites)

Instructions:

  1. Complete and save this form for each CACFP site every October. Enter the Sponsor name, Site name, the month and year.To request a new OMER for a later month (in addition to October), contact your assigned Specialist (For-Profit centers see note below).
  2. CIS/CEF #: This number will be used to connect Confidential Income Statements (CIS) and CACFP Child Enrollment Forms (CEF) to each participant name. Assign a number to each participant. When multiple participants are listed on a CIS and/or CEF, assign the same “CIS/CEF #” number on this roster to each participant listed on the CIS/CEF.
  3. Participant Name: Participants listed must have current CACFP Child Enrollment Forms (CEF) on file for the OMER month. Number the CEF in the upper right corner, using the assigned “CIS/CEF #” on the roster. Outside School Hours Centers (OSHC)will use Sponsor’s own enrollment documents to determine participants to be listed.
  4. Eligibility Determination: Check the box for the approved eligibility category from the most recent Confidential Income Statement (CIS). Number the CIS in the upper right corner, using the assigned “CIS/CEF#” on the roster. (CIS must be approved by the sponsor official nolater than the last day of the OMER month.)
  5. Current CACFP Enrollment Date: Enter the parent/guardian signature date from the most recent CEF.OSHC do not complete.
  6. Transfer or Drop Date: Enter the date that the participant left the site or program.

AGENCY/SPONSOR NAME / CNPweb SITE NAME / MONTH / YEAR
OMER (One Month Enrollment Report)
Totals for all pages to be entered on CNPweb Site Claim / Free / Reduced Price / Above Scale
Roster # / CIS/CEF # / PARTICIPANT NAME
Last name, First name / ELIGIBILITY
DETERMINATION / SPONSOR OFFICAL CIS DETERMINATION DATE / CURRENT CACFP ENROLLMENT FORM DATE / FOR-PROFIT SITES ONLY: SUBSIDIZED CARE(TITLE XX) PMT DATE
see note below / TRANSFER
OR
DROP DATE
F / RP / AS
1
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TOTALS FOR THIS PAGE / If Last Page of Roster
enter in OMER block on page 1
For-Profit sites: Keep this form current for each month of the fiscal year; starting with the month prior to CACFP approval, or October, whichever is latest. At a minimum 25 percent of the enrolled participants or licensed capacity, whichever is less, must be eligible for free and reduced price meal reimbursement according to the USDA’s household size and income guidelines; OR, that a minimum 25 percent of the enrolled participants or licensed capacity, whichever is less, must be receiving State and/or Federally subsidized care (Title XX). If using Title XX to determine if the site is eligible: Record the Title XX (State pay) remittance notice date for the claim month.
I hereby certify that all of the above enrollment and eligibility information for current participants is true and correct and that records are available to support this document.
NAME AND SIGNATURE OF SPONSOR REPRESENTATIVE / DATE

OREGON DEPARTMENT OF EDUCATIONPage 2 of

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

ONE MONTH ENROLLMENT ROSTER (OMER)

(Child Care Centers, Head Start Programs, Outside School Hours Centers)

Roster # / CIS/CEF # / PARTICIPANT NAME
Last name, First name / ELIGIBILITY
DETERMINATION / CIS SPONSOR OFFICAL DETERMINATION Date / CURRENT CACFP ENROLLMENT FORM DATE / FOR-PROFIT SITES ONLY: SUBSIDIZED CARE(TITLE XX) PMT DATE / TRANSFER
OR
DROP DATE
F / RP / AS
16
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TOTALS FOR THIS PAGE
Totals from page 1
TOTAL all pages
If Last Page of Roster enter in OMER block on page 1

OREGON DEPARTMENT OF EDUCATIONPage 3 of

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

ONE MONTH ENROLLMENT ROSTER (OMER)

(Child Care Centers, Head Start Programs, Outside School Hours Centers)

Roster # / CIS/CEF # / PARTICIPANT NAME
Last name, First name / ELIGIBILITY
DETERMINATION / CIS SPONSOR OFFICAL DETERMINATION Date / CURRENT CACFP ENROLLMENT FORM DATE / FOR-PROFIT SITES ONLY: SUBSIDIZED CARE(TITLE XX) PMT DATE / TRANSFER
OR
DROP DATE
F / RP / AS
46
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TOTALS FOR THIS PAGE
Totals from Page 2
TOTAL all pages
If Last Page of Roster enter in OMER block on page 1

OREGON DEPARTMENT OF EDUCATIONPage 4 of

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

ONE MONTH ENROLLMENT ROSTER (OMER)

(Child Care Centers, Head Start Programs, Outside School Hours Centers)

Roster # / CIS/CEF # / PARTICIPANT NAME
Last name,First name / ELIGIBILITY
DETERMINATION / CIS SPONSOR OFFICAL DETERMINATION Date / CURRENT CACFP ENROLLMENT FORM DATE / FOR-PROFIT SITES ONLY: SUBSIDIZED CARE(TITLE XX) PMT DATE / TRANSFER
OR
DROP DATE
F / RP / AS
76
77
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105
TOTALS FOR THIS PAGE
Totals from page 3
TOTAL all pages
If Last Page of Roster enter in OMER block on page 1

OREGON DEPARTMENT OF EDUCATIONPage 5 of

CHILD NUTRITION PROGRAMS

CHILD AND ADULT CARE FOOD PROGRAM

ONE MONTH ENROLLMENT ROSTER (OMER)

(Child Care Centers, Head Start Programs, Outside School Hours Centers)

Roster # / CIS/CEF # / PARTICIPANT NAME
Last name,First name / ELIGIBILITY
DETERMINATION / CIS SPONSOR OFFICAL DETERMINATION Date / CURRENT CACFP ENROLLMENT FORM DATE / FOR-PROFIT SITES ONLY: SUBSIDIZED CARE(TITLE XX) PMT DATE / TRANSFER
OR
DROP DATE
F / RP / AS
106
107
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135
TOTALS FOR THIS PAGE
Totals from page 4
TOTAL all pages
If Last Page of Roster enter in OMER block on page 1