Wellness Policy Assessment Tool and Report Template   




Federal regulations at 7 CFR 210.31 require local education agencies (LEAs) participating in the National School Lunch Program to complete an assessment of their local school wellness policy at least once every three years and make the results available to the public. This triennial assessment must measure the implementation of the local school wellness policy and include:

The extent to which schools under the jurisdiction of the LEA are in compliance with the local school wellness policy;

The extent to which the LEA’s local school wellness policy compares to model local school wellness policies; and

A description of the progress made in attaining the goals of the local school wellness policy.


LEAs may use a variety of methods to assess compliance and determine progress of their goals and objectives. Action planning documents that contain timelines, goals, and key tasks may assist in assessing changes over time. For example, the School Health Index (SHI) from the Centers for Disease Control and Prevention is a comprehensive self-assessment tool that helps with action planning and recordkeeping (a shorter version of the SHI is available from Alliance for a Healthier Generation), and the WellSAT 3.0 is an online tool that indicates the strengths and weaknesses of your written policy.


Triennial Assessment Tool and Report Template


When completed in full, this form may serve as both a triennial assessment tool and public report to meet the requirements in federal regulations and prepare for the Administrative Review by the Pennsylvania Department of Education (PDE), Division of Food and Nutrition. This document is intended to be completed using LEA-level information; however, the LEA may determine that a report from each school site, or alternatively, each school level (i.e., elementary, middle, high school) works better in assessing compliance and progress over time. For larger school districts, reporting on a district level may be challenging due to variation in sites’ programs and progress in attaining wellness goals. If completing this report for the entire LEA, answer questions using the best available information and consider noting individual building variations or concerns in the “notes” sections.

In the left columns, indicate whether the listed goal or practice is included in your local school wellness policy. Bolded policy elements are required by federal regulation. When bolded items are not in the local policy, include an explanation. This tool uses the Pennsylvania School Boards Association’s school wellness policy template (available on PDE’s Local School Wellness Policy Information webpage) as the model wellness policy for comparison purposes, but it can be used regardless of the template used to develop your local policy.

In the right columns, indicate implementation of the goal or practice at schools within the LEA. LEAs are always encouraged to develop additional policy elements and goals for schools under their jurisdiction to create a supportive environment for student nutrition and physical activity.

Space is provided at the end of the form for the LEA to describe the progress made in attaining the goals of the local school wellness policy as required.


Rev. January 2021              This institution is an equal opportunity provider