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pdfAppendix A-7
Local Clinic Program Information Form
Local WIC Clinic
Program Information Form
Implementation Study of the Loving Support Peer Counseling Program
(This form will be sent to local WIC clinics two weeks prior to the site visit to prepare so they
are able to prepare for the interview.)
OMB Clearance Number: xxxx-xxxx
Expiration Date: xx/xx/xxxx
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-XXXX. The time
required to complete this information collection is estimated to average 30 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, ORNA,
Alexandria, VA 22302.
Program Data to Be Collected
Thank you for participating in the implementation study of the Loving Support peer counseling program.
As you know, we will be conducting a site visit with you to learn more about how your clinic implements
the program. As part of the site visit, we will ask you for some information about your program
operations, which you might like to prepare ahead of time. If you would prefer to, you can complete the
information now or you can wait and the site visitor will complete it with you. For each of the items, we
will also be asking for more contextual details.
Breastfeeding or Loving Support Peer Counseling Coordinator (If there is no
Breastfeeding or Loving Support Peer Counseling Coordinator in your clinic, you can skip to the next
section.)
A. What are the breastfeeding coordinator’s duties as they relate to Loving Support peer counseling?
Supervise and monitor work performance of Loving Support peer counselors
Develop basic policies and procedures for local Loving Support peer counseling program
Conduct needs assessment to target the WIC Loving Support peer counseling services
Provide training to local WIC staff (other than peer counselors) about breastfeeding and peer
counseling
Provide training to peer counselors about peer counseling duties and responsibilities
Initiate or serve as point of contact for community organizations that collaborate on Loving
Support peer counseling activities
Develop and implement outreach strategies for Loving Support peer counseling
Design and/or participate in evaluation of local WIC peer counseling services
Conduct Loving Support peer counseling program promotion with local organizations in the
community
Provide information to WIC clients about the peer counseling program
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Monitor Loving Support peer counseling implementation (e.g., peer counseling caseloads,
number of women served, breastfeeding initiation and duration rates among WIC participants,
etc.)
Report on Loving Support peer counseling program operations to State WIC administrative
staff
)
Other (Specify:
B. Is any of his/her salary supported by the FNS peer counseling grant?
Yes, fully supported by Loving Support peer counseling funding
Yes, partially supported by Loving Support peer counseling funding
No, not funded by Loving Support peer counseling funding
Loving Support Peer Counselors
Please list the first names of each of the peer counselors at your clinic, and indicate the number of hours
per week, on average, that they work and the percentage of their salaries/earnings that are supported by
the FNS peer counseling grant.
Peer Counselor Names and Staffing Chart
First Name
Hours
Worked/
Week
Peer Counselor #1
Peer Counselor #2
Peer Counselor #3
Peer Counselor #4
Peer Counselor #5
Peer Counselor #6
Peer Counselor #7
Supported by
FNS peer
counseling
grant?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
IF YES, %
salary/earnings
supported by
FNS peer
counseling grant
%
%
%
%
%
%
%
Information about Contacting WIC Participants
C. Do you track contacts with participants who receive Loving Support peer counseling each month?
No
Yes. If yes, please answer Questions D and E.
D. What is the average number of contacts made in a month for all peer counselors combined?
_______ contacts per month
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E. How do the contacts break down according to those that occur in the WIC offices, in the hospital, by
mail, over the phone, or other? In the last reported month, number of contacts:
___ in the WIC office
___ in the hospital
___ by mail
___ over the telephone
___ other (specify)
Policies about Frequency of Contact
In addition to responding to requests for assistance, do you have any general practice or
policy about the frequency of contact during the following time periods? (See table below.)
Frequency of Contact Chart
At least 1 time every…
No
guidelines
1 week
2 weeks
1
month
2
months
3
months
During 1st trimester
___ contacts per _____
During 2nd trimester
___ contacts per _____
During 3rd trimester
___ contacts per _____
___ contacts per _____
___ contacts per _____
___ contacts per _____
Other time period (Specify #
of contacts per time period)
During pregnancy
After Delivery
Week 1 (after hospital stay)
Weeks 2 – 4
Months 2 – 4
___ contacts per _____
Months 4 – 6
___ contacts per _____
After 6 Months
___ contacts per _____
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F. The frequency of contact specified above is
general practice
more formal guidelines
a combination of general practice and guidelines
**If frequency of contact is determined by a combination of general practice and guidelines,
please explain.
Documentation of Sessions
G. What do peer counselors record/document about peer counseling activities? (Select all that apply.)
Location of contact
Method of contact (e.g., home visit, phone)
Topics/issues discussed with client
Unsuccessful contacts
Materials sent
Demographic information about mother and baby
Referrals made
Status of WIC participant in terms of initiation, duration, exclusivity of breastfeeding
Other (Specify:
)
H. How is this information recorded?
I.
On paper records
In local centralized data base
In state centralized data base
Other method (Please specify:______________________)
How often is this information recorded?
At each client contact
Once a week
Once every two weeks
Once a month
Other (Specify:__________________________________)
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Loving Support Training Chart
In the table below, please indicate the types of training provided to WIC staff and peer
counselors.
WIC Staff
Received once
Peer Counseling Staff
Received more
than once
Received once
Received more
than once
a.
Loving Support peer counseling training
b.
Other locally and/or State-offered training on
breastfeeding and/or role of peer counselors
c.
Lactation management training approved
through IBCLSC Continuing Education
Recognition Points (CERPs)
d.
Other lactation courses that award certificates
e.
Training in filling out paperwork or data entry
f.
Other (Specify:) ________________________
Hospital Policy Chart
In the table below, please describe the policies for up to three hospitals where WIC participants
from your agency most frequently deliver.
a.
Has this hospital been designated a Baby-Friendly Hospital,
as outlined by UNICEF and the World Health Organization?
b.
Is there rooming in for newborns?
c.
Are mothers encouraged to breastfeed within the first hour
after birth?
d.
Are breastfeeding infants routinely given any
supplementation, including water?
e.
Are formula discharge packs provided?
f.
Are there lactation consultants on staff?
g.
Have hospital staff received training in lactation
management in the last 3 years?
Abt Associates Inc.
Hospital A
Yes
No
Don’t know
IF YES, go to
Hospital B
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Hospital B
Yes
No
Don’t know
IF YES, go to
Hospital C
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Hospital C
Yes
No
Don’t know
IF YES, you have
completed the form.
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
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| File Type | application/pdf |
| File Title | Microsoft Word - Appendix cover pages.doc |
| Author | NicholsonJ |
| File Modified | 2007-12-21 |
| File Created | 2007-12-21 |