National Survey of WIC Participants

APPENDIX G
DATA COLLECTION INSTRUMENT FOR WIC TERMINATIONS (DENIED RECERTIFICANTS)

Public reporting burden for this collection of information is estimated to average 6 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. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of
Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0484).

OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

TERMINATIONS -- 1-30-09

WIC Terminations (Denied Recertificants) Survey
PART 1: PRE-CODED FROM AGENCY DATA
P1. Sampled Recertificant
a. Name: _______________________________
b. Address: ______________________________
______________________________
c. Phone number(s): ______________________
P2. Information on sampled Recertificant
a. Category
 Pregnant
 Breastfeeding
 Postpartum
 Infant (<12 months)
 Child (1 - < 5 years)

b. Parent/Guardian (IF APPLICABLE)
Name: __________________
Address: ________________
Phone: _________________

P3. State where local agency is located: _________
1.
2.
3.
4.
5.

Alabama
Arizona
California
Colorado
Florida

6.
7.
8.
9.
10.

Georgia
Illinois
Indiana
Kansas
Louisiana

11.
12.
13.
14.
15.

Maryland
Massachusetts
Michigan
Missouri
New Jersey

16.
17.
18.
19.
20.

New York
North Carolina
Ohio
Pennsylvania
Tennessee

21. Texas
22. Virginia
23. Washington

P4. Region where local agency is located: ____________
Northeast Region =1
Massachusetts
New York
Seneca Nation, NY
Mid-Atlantic Region =2
Maryland
New Jersey
Pennsylvania
Virginia

Southeast Region=3
Alabama
Florida
Georgia
North Carolina
Tennessee
Eastern Cherokee, NC
Midwest Region=4
Illinois
Indiana
Michigan
Ohio

Southwest Region =5
Louisiana
Texas
Western Region =6
Arizona
California
Washington
Inter-Tribal Council, AZ
Navajo Nation, AZ
Mountain Plains =7
Colorado
Kansas
Missouri
Ute Mountain Ute Tribe, CO

P5. Administration of local agency: _________
1) By State directly
2) By local government
3) By public or private third party organization
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Expiration Date: XX/XX/20XX

TERMINATIONS -- 1-30-09

PART 2: DENIALS TELEPHONE SURVEY

SCREENER
SA. NAME OF DENIED RECERTIFICANT
SAMPLED…

_______________________
THIS IS “RECERTIFICANT”

SB. NAME OF PERSON REPRESENTING DENIED
RECERTIFICANT… [WRITE NAME AGAIN, IF
NO OTHER PERSON NOTED IN AGENCY
RECORDS]

________________________
THIS IS “REPRESENTATIVE”

 Contact made by Phone
 Non- Contact Reasons:
____ No Answer
____ Normal Busy
____ Answering Machine
____ Wrong Number
1. Hello, may I speak to [WIC PARTICIPANT]______________?
A. Yes [WHEN R. IS REACHED, CONTINUE]
No [GET TIME AND DATE WHEN R. CAN BE REACHED. TERMINATE.]
B. Time _______

Date___________

This is ____________ of Macro International calling on behalf of the USDA’s WIC Women,
Infants and Children food program. According to the agency’s records, [INSERT “you” OR
RECERTIFICANT’S NAME] recently applied for WIC food benefits and, apparently, were/was turned
down. We are conducting a confidential survey among people who got turned down so that we can
see if the agency is following correct procedures. Your responses are anonymous and will not be
shared with the local WIC agency.
This survey takes approximately 5 minutes. Because it is confidential, it won’t change the decision.
However, if in our conversation it appears that the local WIC agency may have made a mistake,
you may want to apply for the WIC benefits again. And, of course, we will be recommending
changes if problems are found.
ADD INFORMED CONSENT LANGUAGE FROM IRB.

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Expiration Date: XX/XX/20XX

TERMINATIONS -- 1-30-09

P1. May we continue?
___ ACCEPT [SKIP TO Q1]
___ REFUSE [SKIP TO P3]
___LANGUAGE ISSUES [CONTINUE TO P2]
P2.

IF POSSIBLE LANGUAGE DIFFICULTIES, ASK: May we continue in English?

 YES [CONTINUE]
 NO [ASK “What language do you speak?” AND RECORD ANSWER. IF

QUESTION NOT UNDERSTOOD, ASK “Español?” OR OTHER LIKELY
LANGUAGE (AS PRECODED IN P2j) AND RECORD ANSWER. TELL R. YOU
WILL CALL BACK LATER.]

P3. IF REFUSAL, SAY: This research is really important to the WIC program – to make sure
mistakes don’t get made in turning people away who want to be get benefits. We’re actually
interviewing lots of people like you all over the country. So your answers and identity will just
be grouped with others in your situation. Like I said, it’s confidential and it only takes about 5
minutes.




SEE IF R. WILL DO INTERVIEW NOW.
IF YES, GO BACK TO P1; CHANGE TO ACCEPT, THEN CONTINUE
IF NOT, SEE IF R. SUGGEST TIME/DATE AND NEGOTIATE AS INTERVIEWER’S
SCHEDULE PERMITS.

TIME___________ DATE _____________ (ENTER “0” IF R. REFUSES)


IF R. STILL REFUSES, THANK & TERMINATE.

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OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

TERMINATIONS -- 1-30-09

TELEPHONE SURVEY
Public reporting burden for this collection of information is estimated to average 6 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. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and
Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0484).

1. Let me start by asking how you heard about the WIC – Women, Infants and Children –
program? [CHECK ALL THAT APPLY]
 FRIEND/COLLEAGUE/CO-WORKER
 FAMILY MEMBER
 DOCTOR/HEALTH PROFESSIONAL
 TELEVISION ADVERTISEMENT
 RADIO ADVERTISEMENT

 NEWSPAPER
 BILLBOARD
 OTHER: SPECIFY ______________________

2. Which of the following benefits were you interested in getting out of the WIC program? You
can answer yes or no. Were you interested in…[INSERT FROM BELOW]:
a. The food package or coupons to get healthy food?

YES

NO

b. Health and nutrition classes and individual
counseling?

YES

NO

c. Support for breastfeeding your baby?

YES

NO

d. Information about immunizations for your child(ren)?

YES

NO

e. Information on how to get other health care services
for your family?

YES

NO

f. Information about what other community programs
are available to help your family?

YES

NO

3. When you went to apply for WIC benefits, [INSERT “you were” OR “RECERTIFICANT’S NAME
was”] turned down. Did the WIC clinic give you any reason for turning you down that was
related to proof of identity, that is showing identification?
YES [CONTINUE TO Q3A]
NO [SKIP TO Q4]
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3A.What reason did they give? [IF MORE THAN ONE IS MENTIONED, ASK “WHICH WAS THE
MAIN REASON GIVEN?”]
 RECERTIFICANT DID NOT HAVE PROOF WITH THEM AT WIC AGENCY
 EXPIRED DATE ON PROOF
 UNACCEPTABLE TYPE OF PROOF
 PROOF WAS MISSING NAME
 PROOF WAS MISSING PHOTO
 OTHER: SPECIFY ____________
3B. Did you see their point or do you feel they made a mistake?
 SAW THEIR POINT
 MADE A MISTAKE
3C. Did the WIC representative say anything about what you could do to change the
decision, such as what items you could bring back to help yourself qualify for benefits?
 YES
 NO
4. Was a reason given related to showing proof that [You/OR NAME OF RECERTIFICANT]
live/s, that is resides, in the right area?
 YES [CONTINUE TO Q4A]
 NO [SKIP TO Q5]
4A. What reason did they give? [IF MORE THAN ONE IS MENTIONED, ASK “WHICH WAS THE
MAIN REASON GIVEN?”]
 RECERTIFICANT DID NOT HAVE PROOF WITH THEM AT WIC
AGENCY
 EXPIRED DATE ON PROOF
 UNACCEPTABLE TYPE OF PROOF
 PROOF WAS MISSING NAME
 PROOF WAS MISSING PHOTO
 PROOF WAS MISSING ADDRESS
 ADDRESS WAS NOT IN LOCAL AGENCY’S COVERAGE AREA
 OTHER: SPECIFY ____________
4B. ASK: Did you see their point or do you feel they made a mistake?
 SAW THEIR POINT
 MADE A MISTAKE

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4C. Did the WIC representative say anything about what you could do to change the
decision, such as what items you could bring back to help yourself qualify for benefits?
 YES
 NO
5. Was a reason given related to [Your/OR NAME OF RECERTIFICANT’s] income?
 YES [CONTINUE TO Q5A]
 NO [SKIP TO Q5C]
5A. What reason did they give? [IF MORE THAN ONE IS MENTIONED, ASK “WHICH WAS THE
MAIN REASON GIVEN?”]

 DID NOT HAVE INCOME PROOFS WITH THEM AT THE WIC AGENCY
 EXPIRED DATE ON PROOF
 UNACCEPTABLE TYPE OF PROOF
 PROOF WAS MISSING NAME
 INCOME WAS TOO HIGH
 OTHER: SPECIFY ____________
5B. Did you see their point or do you feel they made a mistake?
 SAW THEIR POINT
 MADE A MISTAKE
5C. Did the WIC representative say anything about what you could do to change the
decision, such as what items you could bring back to help yourself qualify for benefits?
 YES
 NO
5D. [IF Q5A=INCOME WAS TOO HIGH , SKIP TO Q6.] When it turned out that you didn’t
have the right documents with you at the WIC office… [INSERT FROM BELOW]?
a. Were you given a new appointment with WIC after
they refused to certify you?
b. Did they ask you to describe your income?

YES

NO

YES

NO

c. Did they give you a month of temporary WIC food
benefits?
d. Did they instruct you to come back with the proof in
30 days or so?

YES

NO

YES

NO

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OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

TERMINATIONS -- 1-30-09

6. [IF Q3 IS “NO” OR Q3B IS “SAW THEIR POINT”, SKIP TO Q7.] You said you did not
agree with their decision about your identification proofs…
FOR EACH ITEM
CHECKED IN Q6A,
ASK Q6B and Q6C.
A. What did you show them to identify
yourself? [DO NOT READ. CHECK
ALL THAT APPLY.]

B. Who issued this
item? [PROBE TO
CLARIFY]

 DRIVER’S LICENSE
PASSPORT
IDENTIFICATION CARD
OTHER ITEM: PLEASE SPECIFY
____________________________
NOTHING [SKIP TO Q7]
DON’T KNOW/ REMEMBER [SKIP TO Q7]

FEDERAL GOVT/AGENCY
STATE GOVT/AGENCY
LOCAL GOVT/AGENCY
PRIVATE COMPANY
COURT SYSTEM
FOREIGN GOVERNMENT
OTHER
DON’T KNOW/REMEMBER

C. Did it
have your
name and
your photo
on it?
YES
NO

7. [IF Q4 IS “NO” OR Q4B IS “SAW THEIR POINT”, SKIP TO Q8.] You said you did not
agree with their decision about your proof of residence (that is, address)…
FOR EACH ITEM
CHECKED IN Q5a,
ASK Q5b and Q5c:
A. What items did you show them to
prove your address? [DO NOT READ.
CHECK ALL THAT APPLY. ]
DRIVER’S LICENSE
IDENTIFICATION CARD
CURRENT UTILITY/TAX BILL
CHECKBOOK
RENT RECEIPT, MORTGAGE RECEIPT OR LEASE
WRITTEN STATEMENT BY 3RD PARTY
OTHER ITEM: PLEASE SPECIFY
____________________________
NOTHING [SKIP TO Q8]
DON’T KNOW/ REMEMBER [SKIP TO Q8]

B. Who issued this item? C. Did it
[PROBE TO
have your
CLARIFY]
name and
address on it?
FEDERAL GOVT/AGENCY
STATE GOVT/AGENCY
YES
LOCAL GOVT/AGENCY
NO
PRIVATE COMPANY
COURT SYSTEM
FOREIGN GOVERNMENT
NON-PROFIT
ORGANIZATION

RELIGIOUS ORGANIZATION
OTHER
DON’T KNOW/REMEMBER

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TERMINATIONS -- 1-30-09

8. [IF Q5 IS “NO” OR Q5B IS “SAW THEIR POINT”, SKIP TO Q9.] You said you did not
agree with their decision about you or your family’s income…
A. What proofs or documents did you show them to
demonstrate income? [DO NOT READ. CHECK ALL
THAT APPLY.]
MOST RECENT TAX RETURN
FOOD STAMPS
W-2 FORM
MEDICAID
STATEMENT FROM BANK OR OTHER TANF
FINANCIAL INSTITUTION
SUPPLEMENTAL SECURITY
INCOME (SSI)
CHECK OR PAY STUB
SIGNED STATEMENT BY EMPLOYER FOOD DISTRIBUTION
PROGRAM ON INDIAN
ELIGIBILITY LETTER SIGNED BY
RESERVATIONS (FDPIR)
OFFICIAL STATE/LOCAL AGENCY
CHILDREN’S MEDICAID
STATEMENT OF BENEFITS (BY
PUBLIC AGENCY OR COURT)
FREE/REDUCED-MEAL
SCHOOL LUNCH/
WRITTEN STATEMENT FROM
BREAKFAST PROGRAM
RELIABLE THIRD PARTY
LOW-INCOME ENERGY ASSISTANCE
OTHER ITEM: PLEASE SPECIFY
NOTHING
DON’T KNOW/ REMEMBER

B. Who issued this item?
[PROBE TO CLARIFY]
FEDERAL GOVT/AGENCY
STATE GOVT/AGENCY
LOCAL GOVT/AGENCY
PRIVATE COMPANY
COURT SYSTEM
FOREIGN GOVERNMENT
NON-PROFIT ORGANIZATION
RELIGIOUS ORGANIZATION
OTHER
DON’T KNOW/REMEMBER

_________________

9. Did you take any follow-up actions to see if you could get the decision changed?
 YES
 NO [SKIP TO Q11]
10. What action did you take? [DON’T READ. CHECK ALL THAT APPLY. THEN SKIP TO Q12.]
 WROTE LETTER OF COMPLAINT, PROTEST TO WIC
 ASKED TO SPEAK TO, OR DID SPEAK WITH, WIC SUPERVISOR
 COMPLAINED TO AN ELECTED PUBLIC OFFICIAL
 MADE A PHONE CALL AFTERWARDS, CHALLENGING THE DECISION
 OTHER: SPECIFY: _________________
11. Why not?

 TOO BUSY
 DON’T SPEAK ENGLISH WELL
 IT WOULDN’T DO ANY GOOD
 OTHER: SPECIFY: _________________

I just have a couple more questions for categorization purposes only.
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SKIP IF KNOWN FROM PART 1:
12. Are you… [READ]
 Hispanic or Latino?
 Not Hispanic or Latino?
 REFUSED
SKIP IF KNOWN FROM PART 1:
13. How would you characterize yourself in terms of race? [READ ALL.]
 American Indian or Alaska Native
 Asian American
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Multiracial (Two or more of the above)
 REFUSED
14. What is the highest level of education you have attained? [READ UNTIL R. INDICATES
ANSWER]
 Elementary school (6 years or less of education)
 Some high school (7 – 11 years of education)
 High school diploma or GED
 Some college
 Associate’s degree
 Bachelor’s degree
 Advanced degree
 REFUSED
15. What is your first language, that is, the language you speak at home?
 English
 Hmong
 Spanish
 Arabic
 Khmer
 Swahili
 Cambodian
 Korean
 Tamil
 Cantonese/ Mandarin
 Laotian
 Tagalog
 Farsi
 Punjabi
 Urdu
 French/Creole
 Russian
 Vietnamese
 Fulani
 Somali
 Other: SPECIFY
_________
 Hindi
Thank you so much for your help in answering this survey. Your feedback, combined with other
anonymous responses, will help improve the WIC program. Thanks again.
Have a great day/evening.
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