After You Deliver

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OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, an agency may not conduct
or sponsor, and a person is not 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 0584-0524. The time required to
complete this information collection is estimated to average 10 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. If you have any comments concerning the accuracy of time estimates
or suggestions for improving this form, please contact: U. S. Department of Agriculture, Food and Nutrition
Service, Office of Research, Nutrition and Analysis, Alexandria, VA 22302.

WIC Brochure “After You Deliver”
Participant Screening Questionnaire
NOTE TO USDA
To observe participants’ privacy APR will use the Participant Screening Questionnaire only with
those WIC participants who contact our firm directly in response to promotional information
they receive about the focus groups through their local agency.

[Recruit 20 respondents to obtain 15 participants for each of the 5 focus groups.]
Hello, my name is ___________. I am with Annapolis Professional Resources, Inc. and I am
contacting you about the WIC Focus Group Study that you are interested in participating in. I am
going to ask you some questions that will help to make a decision about your participation. If
you are selected to participate, the focus group session will give you and other WIC Program
participants an opportunity to share your opinions about the brochure “After You Deliver”.
1.

Are you a current participant in the WIC Program or have you participated in the WIC
Program in the last 6 months? [Record each “YES” response.]
Yes ................................................................. ( )
No .................................................................. ( )

2.

Terminate if “NO”

Are you currently breastfeeding or have you breastfed any of your children in the past?
[Record each “YES” response.]
Yes ................................................................. ( )
No .................................................................. ( )
[Collect breastfeeding data for information purposes only, not as a “rule in” or
“rule out.”]

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3.

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What is your current age? ____ [Specify]
[Collect age data for information purposes only, not as a “rule in” or “rule out.”]

4.

Do you have reliable transportation to the place where the focus group will be conducted?
The focus group will be conducted at:
Address
Address
City, State and Zip
Yes ................................................................. ( )
No .................................................................. ( )
Maybe ........................................................... ( )
following transportation options:

If “MAYBE” inquire about the

Check each option for which respondent answers “yes”
ˆ Ride from family member or friend ...... ( )
ˆ Public transportation .............................. ( )
ˆ Voucher for transportation .................... ( )
ˆ Taxi ........................................................... ( )
ˆ Walking .................................................... ( )
ˆ Other means of transportation............... ( ) If “OTHER MEANS” state below
_________________________________
5.

Will you be available to stay for the entire 2-hour focus group session?
Yes ................................................................. ( )
No .................................................................. ( )

6.

Terminate if “NO”

What is the highest level of education you have completed? [DO NOT read list]
Elementary school ......................................... (
Middle/junior high school.............................. (
Some high school .......................................... (
High school graduate, some college,
vocational or technical school ....................... (
College graduate ........................................... (
Post college ................................................... (

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)
)
)
)
)
)

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7.

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What is your race and ethnicity?
[Read list and record one answer for both categories.]
Race
American Indian or Alaska Native ................ (
Asian ............................................................. (
Black or African American ........................... (
Hispanic or Latino ......................................... (
Native Hawaiian or Other Pacific Islander ... (
White.............................................................. (

)
)
)
)
)
)

Ethnicity
Hispanic/Latino ............................................. ( )
Not Hispanic/Not Latino ............................... ( )
8.

What is the primary language you speak? [DO NOT read list]
English .......................................................... ( )
Spanish........................................................... ( )
Other ............................................................. ( ) If “OTHER” is not Spanish, inquire
and record the other language ____________________________________________

No. 9 & 10 - FOR RESPONDENTS WHO INDICATED HISPANIC OR LATINA ONLY

9.

Do you speak both English and Spanish equally well?
Yes ................................................................. ( )
No .................................................................. ( )
language they speak the best and record below

If “NO” inquire about which

________________________________________
10.

Do you read both English and Spanish equally well?
Yes ................................................................. ( )
No .................................................................. ( )
language they speak the best and record below

If “NO” inquire about which

________________________________________

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11.

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Why are you interested in participating in the WIC Program focus group?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

12.

Have you ever been employed by USDA, a state agency, or a local agency to work on the
WIC Program?
No .................................................................. ( ) Continue
Yes ............................................................... ( ) Terminate
Don’t know/Refused .................................... ( ) Terminate
[After recording respondent’s answer, determine whether or not you feel this
respondent would be useful in the group. Did she:
Give a full and complete answer?
Speak clearly, and without long pauses?
Answer enthusiastically?
It is most important that the respondent be understandable! If not, terminate.]
Note
If you feel this individual would be a good candidate for the focus group, is available to attend
the full session, and has reliable transportation, continue with #13 below.

13.

I would like to invite you to participate in a focus group discussion. The session will last
approximately two hours. You will be required to arrive 15 minutes early for the session.
Annapolis Professional Resources will contact you with a confirmation message that
contains all the details about your session.
During the focus group, you will have an opportunity to share your thoughts and opinions
with other WIC Program participants from your area. You will not be asked to buy any
products.
For participating in the focus group, you will receive $75 in cash at the end of the
session. Would you be willing to participate?
Yes ................................................................ ( ) SCHEDULE
No ................................................................. ( ) THANK & END

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GROUP TYPE

DAY

TIME

_________________________

_______________

_______

We will call you to remind you of this appointment. However, if for some reason you are
unable to attend, please call (TELEPHONE NUMBER) so that we can find a
replacement for you.
Thank you.

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