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pdfAPPENDIX E
DATA COLLECTION INSTRUMENT FOR WIC PARTICIPANTS
VERSION A: PREGNANT, BREASTFEEDING AND POST-PARTUM
VERSION B: INFANTS AND CHILDREN
Public reporting burden for this collection of information is estimated to average 24 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
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
WIC Participants Survey
PART 1: PRE-CODED FROM AGENCY DATA
NOTE: TO MAINTAIN CONSISTENCY OF NUMBERING FOR THE SAME
ITEMS ACROSS VERSIONS, SOME NUMBERS MAY BE EXCLUDED.
P1. Sampled participant
a. Name:
b. Address:
________________________________
________________________________
________________________________
c. Phone number(s): ________________________________
________________________________
P2. Information on sampled participant from state/local records
a. Category
Pregnant
Breastfeeding [SKIP TO P2d]
Postpartum [SKIP TO P2d]
b. THIS QUESTION NUMBER DELIBERATELY SKIPPED
c.
Start date of current certification for this pregnancy (MM/DD/YYYY).
[SHOULD BE PRIOR TO JULY 31, 2008]
_____ / _____ /_____
d.
Start date of original certification for this pregnancy. [MAY BE SAME AS
P2c OR EARLIER.] (MM/DD/YYYY)
_____ / _____ /_____
e. [IF R.=PREGNANT, SKIP TO P2f. FOR BREASTFEEDING &
POSTPARTUM ONLY, NOTE THE FOLLOWING FROM RECORDS:]
Did R. receive benefits while pregnant?
Yes
No
f. Birthdate of participant (MM/DD/YYYY)
_____ / _____ /_____ /
g. Gender of participant
Male
Female
Page E(A)-1
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
h. Is participant..? [IF IN RECORDS. OTHERWISE ASK IN Q49 AT END
OF SURVEY]
Hispanic or Latino?
Not Hispanic or Latino?
Not indicated in records (COMPLETE Q49)
i.
Race/ethnicity of participant [IF IN RECORDS. OTHERWISE ASK IN Q50
AT END OF SURVEY]
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)
Not indicated in records (COMPLETE Q50)
j.
Primary language of participant [IF NOTED IN RECORDS]
English
Arabic
Cambodian
Cantonese/Mandarin
Farsi
French/Creole
Fulani
Hindi
Hmong
Khmer
Korean
Laotian
Portuguese
Punjabi
Russian
Somali
Spanish
Swahili
Tamil
Tagalog
Urdu
Vietnamese
Other: SPECIFY
_________
P3. Do records indicate proof of…?
a.
b.
c.
d.
e.
f.
Identification
Categorical eligibility
Adjunctive income eligibility
Non-adjunctive income eligibility
Residential eligibility
Nutritional eligibility
YES
NO
Page E(A)-2
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
P4. What justification or documents were used to establish…? (NOTE FOR ALL THAT
APPLY)
NOTE ―1‖
IF DOC IS
NOTED IN
FILE;
NOTE ―2‖
IF
ACTUAL
COPY IS
IN FILE
Adjunctive or
other Statedefined automatic
income eligibility
Non-Adjunctive
Residential
income eligibility eligibility
Adjunctive
Most recent tax
Food Stamps
Medicaid
TANF
Children’s
Medicaid
Other State-defined
Supplemental
Security Income
(SSI)
Food Distribution
Program on Indian
Reservations
(FDPIR)
Free/Reduced-
Meal School
Lunch/Breakfast
Program
Low-Income
Energy Assistance
Document
Unspecified
Other: SPECIFY
_____________
None
Nutritional
eligibility
[TYPE IN UP
TO 8 CODES]
return
W-2 form
Statement from
bank or other
financial
institution
Check or pay
stub
Signed statement
by employer
Eligibility letter
signed by official
state/local agency
Statement of
benefits by public
agency or court
Current utility bill,
rent, mortgage
receipt or tax bill
Drivers license __________
Current
__________
utility/tax bill
__________
with address
__________
on it
__________
Written
statement from __________
reliable third
__________
party
__________
Checkbook
Rent receipt,
None
mortgage
receipt or lease
Document
Unspecified
Other:
SPECIFY
____________
None
Written statement
from reliable third
party
Document
Unspecified
Other: SPECIFY
______________
None
Page E(A)-3
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
P5. Number in WIC family/economic unit
a. IF DISCERNIBLE FROM AGENCY RECORDS: Relationships relative to
sampled participant [DO NOT INCLUDE PARTICIPANT]
Relationship to WIC
participant
Adults counted
in WIC family/
economic unit
who are…
(WRITE #)
1.
2.
3.
4.
5.
6.
7.
8.
Spouse
Partner
Son/daughter
Step-son/daughter
Foster child
Parent/Guardian
Step-parent
Foster parent
9. Brother/Sister or
Step-Brother/Sister
10. Grandparent
Infants &
children (<15
yrs) counted in
WIC family/
economic unit
who are…
(WRITE #)
N/A
N/A
How many of total - from columns one
and two -- receive
WIC?
(WRITE #)
N/A
N/A
N/A
N/A
11. Uncle/aunt
12. Cousin
13. Nephew/niece
N/A
14. Father-inlaw/Mother-in-law
N/A
15. Brother-in-law/
sister-in-law
16. Other relative
17. Other non-relative
b. COMPUTER WILL TOTAL COLUMNS FROM ABOVE
Total
Total
These two totals --plus 1 for the
sampled WIC participant --equal
total number of people that LA
considers to be part of family/economic unit
Total
This total --plus 1
for the sampled
WIC participant -equals number of
WIC participants in
family/ economic
unit
Page E(A)-4
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
P6. PRE-CODED ITEMS ABOUT THE LOCAL AGENCY
a) Administration of local agency: _________
1) By State directly
2) By local government
3) By public or private third party organization
b) How does local agency refer to food instruments with its WIC clients? [USE
DATA FROM STATE AGENCY LETTER #1]
1) Food coupons
2) Food checks
3) Food instruments
4) Other: SPECIFY _______________________________
c) What is the name of Food Stamp program in this State? [USE DATA FROM
STATE AGENCY LETTER #1]
[OPEN END]
Page E(A)-5
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
PART 2: WIC PARTICIPANT TELEPHONE SURVEY
SCREENER
SA. NAME OF WIC PARTICIPANT SAMPLED…
SB. NAME OF RESPONDENT TO BE INTERVIEWED. THIS WILL BE A PARENT,
GUARDIAN OR FOSTER PARENT IF WIC
PARTICIPANT IS AN INFANT OR CHILD
_____________________
______________________
USE VERSION A IF Q-SA (SAMPLED PARTICIPANT) AND Q-SB (PERSON
INTEVIEWED) ARE THE SAME. THIS WILL BE ALL PREGNANT,
BREASTFEEDING OR POSTPARTUM PARTICIPANTS
Contact made by Phone
Non- Contact Reasons:
____ No Answer
____ Normal Busy
____ Answering Machine
____ Wrong Number
S1. 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 USDA’S WIC
program from which you are currently receiving food benefits. We are conducting a
confidential survey about what people like about WIC and how WIC can be improved.
You are under no obligation to answer any question, and you can end the interview at any
time. The interview takes approximately 25 minutes, and again, any information you
give us will be confidential.
ADD INFORMED CONSENT LANGUAGE FROM IRB.
S2. May we continue?
___ Accept
___ Refuse
Page E(A)-6
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
S3.
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.]
IF REFUSAL, SAY: This research is really important to the WIC program because they
need to hear feedback from people who use the program. We’re interviewing 2400 WIC
participants, including yourself, all around the country. Your name was randomly chosen
and your answers will be kept confidential and grouped with other people’s answers, so
neither the Food and Nutrition Service nor your local agency will ever know your
specific answers. Nothing you say will change your benefits. The survey shouldn’t take
all that long. You are not required to answer any question, and you can end the interview
at any time. I’d really like to do the survey now. However, if now is inconvenient, we
could schedule a different time.
SEE IF R. WILL DO INTERVIEW NOW.
IF YES, GO BACK TO Q2; 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.
Page E(A)-7
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
TELEPHONE SURVEY
Public reporting burden for this collection of information is estimated to average 24 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).
The questions I am going to ask are about your satisfaction and experiences with WIC.
This takes about 20 minutes and your feedback will be grouped together with answers
from other people. Since your answers are confidential, nothing you say will change
your benefits.
WIC PROGRAM PARTICIPATION
1. Let’s begin by talking about your experience with WIC. Is this the first time you’ve
received WIC benefits for yourself or have you participated before this with another
pregnancy/child? [IF PREGNANT, SAY: pregnancy. IF BREASTFEEDING/
POSTPARTUM, SAY: child]
NEW TO WIC [SKIP TO Q3]
PARTICIPATED BEFORE [CONTINUE]
2. How many times have you participated before? [ASK, THEN SKIP TO Q4]
1
2
3 or more
3. Why didn’t you participate before this? [DO NOT READ; CHECK ALL THAT
APPLY]
THIS IS MY FIRST CHILD/PREGNANCY
DIDN’T LIVE IN USA
DIDN’T KNOW ABOUT WIC
DIDN’T THINK QUALIFIED FOR WIC (FOR CATEGORY REASON)
DIDN’T THINK QUALIFIED FOR WIC (FOR INCOME REASON)
DIDN’T TRUST WIC
DIDN’T QUALIFY FOR WIC
LACK OF TRANSPORTATION TO CLINIC, TRANSPORTATION DIFFICULTIES
SCHEDULE DIFFICULTIES
SERVICES (INCLUDING WAITING TIME) TAKE TOO MUCH TIME
WAITING SPACE AT CLINIC IS LIMITED
LACK OF CHILD CARE
LANGUAGE BARRIERS
PROBLEMS QUALIFYING FOR BENEFITS
Page E(A)-8
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
DIDN’T HAVE PAPERS TO PROVE ELIGIBILITY
DIFFICULTIES KEEPING APPOINTMENT TIMES
WIC FOOD SELECTION NOT DESIRABLE
WIC FOOD STORES NOT CONVENIENT (HOURS OR LOCATION)
WIC FOOD HARD TO FIND ON SHELVES (BRANDS, QUANTITIES)
IMMIGRATION CONCERNS
DIDN’T NEED FOOD BENEFIT
DON’T KNOW
OTHER: PLEASE SPECIFY______________________________
[IF Q3= THIS IS MY FIRST CHILD/PREGNANCY, AUTOMATICALLY CODE Q4 AS THIS IS
FIRST, ONLY CHILD AND SKIP TO Q5.]
4.
0.
1.
2.
3.
4.
5.
6.
7.
8.
9.
[IF R.=PREGNANT, ASK:]
How many other children do you have?
[IF R.=BREASTFEEDING OR POSTPARTUM, ASK:]
How many other children do you have, or is this your first baby?
THIS IS FIRST, ONLY CHILD
1 OTHER CHILD
[CLARIFY: And were these children
2 OTHER CHILDREN
all born to you? IF ANSWER IS NO,
3 OTHER CHILDREN
RE-ASK QUESTION, How many other
4 OTHER CHILDREN
children have been born to you, or
5 OTHER CHILDREN
6 OTHER CHILDREN
is this your first baby?]
7 OTHER CHILDREN
8 OTHER CHILDREN
9 OR MORE OTHER CHILDREN
SKIP TO Q7 IF ANY OF FOLLOWING ARE TRUE:
R.=PREGNANT
R.=BREASTFEEDING AND P2e=YES (i.e. Rec’d benefits when pregnant)
R.=POSTPARTUM IF P2e=YES (i.e. Rec’d benefits when pregnant)
5. According to the records, you did not receive benefits while you were pregnant, that
is, before the baby was born. Is that correct?
YES [CONTINUE]
NO [SKIP TO Q7]
Page E(A)-9
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
6. Why didn’t you participate in WIC while you were pregnant? [DO NOT READ;
CHECK AS MANY AS APPLY]
DIDN’T LIVE IN USA
DIDN’T KNOW ABOUT WIC
DIDN’T TRUST WIC
DIDN’T QUALIFY FOR WIC
LACK OF TRANSPORTATION TO CLINIC, TRANSPORTATION DIFFICULTIES
SCHEDULE DIFFICULTIES
SERVICES (INCLUDING WAITING TIME) TAKE TOO MUCH TIME
WAITING SPACE AT CLINIC IS LIMITED
LACK OF CHILD CARE
LANGUAGE BARRIERS
PROBLEMS QUALIFYING FOR BENEFITS
DIFFICULTIES KEEPING APPOINTMENT TIMES
WIC FOOD SELECTION NOT DESIRABLE
WIC FOOD STORES NOT CONVENIENT (HOURS OR LOCATION)
WIC FOOD HARD TO FIND ON SHELVES (BRANDS, QUANTITIES)
IMMIGRATION CONCERNS
DIDN’T NEED FOOD BENEFIT
DON’T KNOW
OTHER: PLEASE SPECIFY______________________________
SATISFACTION WITH LOCAL CLINIC, SERVICES, FOOD STORES
7. Thinking about the WIC clinic that you are familiar with, how satisfied are you with
the people that work there and the services they provide? Would you say you are
[READ]…?
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied, or
Very Dissatisfied
7a. Thinking about the WIC clinic’s location and building facility, would you say you are
[READ]…?
Very Satisfied
Somewhat Satisfied
Neither Satisfied nor Dissatisfied
Somewhat Dissatisfied, or
Very Dissatisfied
Page E(A)-10
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
Looking at specific qualities or characteristics of the clinic…
8. How would you rate the [INSERT FROM BELOW]? Would you say it is Excellent,
Very Good, Good, Fair or Poor? [REPEAT SCALE UNTIL R. LEARNS IT]
Excellent-----Very Good------Good------Fair------Poor
[ROTATE START POINT]
a) Customer friendliness of the WIC staff
b) Quality of service you get
c) Helpfulness of the staff
d) Staff’s ability to speak your language
e) Safety of the clinic’s location
f) Convenience of the clinic’s location for you
g) Convenience of its operating hours
h) Amount of time you must wait until you are seen by WIC staff
i) Size and space of the waiting area
j) Activities provided to occupy children while you wait
k) Way they handle paperwork for certification
l) How they deliver your food -[INSERT WORD USED IN P6b]
9. Now, think about the food benefits that you receive for yourself. How would you rate
them in the following areas? Use the same scale: Excellent, Very Good, Good, Fair
or Poor. How would you rate the food benefits for…
Excellent-----Very Good------Good------Fair ------Poor
a) Providing the right quantity of food?
b) Offering foods that you like to eat?
c) Offering food choices in sizes and brands that you can find on the shelf? For
example, if the coupon says a 46 oz container of juice in one of these 3
brands, you can find them in the store where you shop.
10. Are there certain WIC foods that, on a regular basis, you do not purchase for some
reason?
YES [CONTINUE]
NO [SKIP TO Q12]
Page E(A)-11
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
11. Which ones do you not purchase? [DO NOT READ LIST. JUST CHECK OFF ALL
THAT APPLY. FOR EACH ONE CHECKED, ASK:] Why not)? AFTER R.
ANSWERS, ASK, Anything else?
ITEMS NOT
REDEEMED
Why don’t you redeem
them? [CODE OR WRITE
IN MAIN REASON]
CARROTS
CEREAL
CHEESE
DRY BEANS,
PEAS
EGGS
FORMULA
JUICE
MILK
PEANUT
BUTTER
TUNA
PRECODES
1 – Dislike, don’t like
2 – Not accustomed to eating it
(including cultural differences)
3 – Food allergies
4 – Don’t know how to prepare
5 – Too much trouble to prepare
6 – Problems getting food to home
7– Couldn’t find/ Lost the food
coupons
8 – Store did not have item in stock
9 – Did not need at that time
10 – Other: SPECIFY
*
12A. For food items you did redeem, was there too much of any food?
YES (Which Foods?.....)
NO (SKIP TO 12b)
[DO NOT READ. JUST CHECK OFF ALL THAT APPLY]
TOO MUCH
CARROTS
CEREAL
CHEESE
DRY BEANS, PEAS
EGGS
FORMULA
JUICE
MILK
PEANUT BUTTER
TUNA
OTHER ____________
Page E(A)-12
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
12B. For food items you did redeem, was there too little of any food?
YES (Which Foods?......)
NO (SKIP TO 13)
[DO NOT READ. JUST CHECK OFF ALL THAT APPLY]
TOO LITTLE
CARROTS
CEREAL
CHEESE
DRY BEANS, PEAS
EGGS
FORMULA
JUICE
MILK
PEANUT BUTTER
TUNA
OTHER __________
13. Which description best fits the store where you most often redeem your WIC food
[INSERT WORD USED IN P6d]? [READ FULL LIST]
Large grocery store or supermarket
Small grocery store
Convenience store
Specialty food store, such as one that specializes in ethnic foods
Store that carries only WIC-approved items
Large combination food store-retailer such as a Walmart or a Target
Military commissary
[IF ILLINOIS, READ]: WIC Food Centers
[DON’T READ] OTHER [ASK: Can you describe it for me? AND TYPE
BRIEF DESCRIPTION ___________________________________]
14. Using the scale of Excellent, Very Good, Good, Fair or Poor that we used earlier,
what overall rating would you give the store where you do most of your WIC
shopping.‖
EXCELLENT
VERY GOOD
GOOD
FAIR
POOR
Page E(A)-13
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
15. Do you buy your WIC items at the same store where you do most of your other
food shopping?
YES [SKIP TO Q17]
NO [CONTINUE]
16. Why not? [DO NOT READ. CODE ANSWER ALL THAT APPLY]
EXPENSE: WIC STORE MORE EXPENSIVE, REGULAR STORE LESS EXPENSIVE
EXPENSE: REGULAR STORE MORE EXPENSIVE, WIC STORE LESS EXPENSIVE
TRANSPORTATION: WIC STORE LESS CONVENIENT TO GET TO, REGULAR STORE
MORE CONVENIENT
TRANSPORTATION: REGULAR STORE LESS CONVENIENT TO GET TO, WIC STORE
MORE CONVENIENT
COURTESY: WIC STORE NOT CUSTOMER-FRIENDLY, REGULAR STORE
FRIENDLIER
COURTESY: REGULAR STORE NOT CUSTOMER-FRIENDLY, WIC STORE
FRIENDLIER
REGULAR STORE DOES NOT PARTICIPATE IN WIC PROGRAM
REGULAR STORE DOESN’T CARRY RIGHT SIZES/SELECTIONS OF WIC FOODS
OTHER: PLEASE SPECIFY ________________________________
17. I am going to give you a list of reasons why some people go to the store that they
do for WIC purchases. For each one, please tell me how important it is to you by
giving a number from 0 to 5, with 5 meaning extremely important and 0 being
Not Important at all. How important is it that [INSERT FROM BELOW]:
Extremely important
Not at all important
5-----------4-----------3-----------2-----------1-----------0
[ROTATE START POINT]
a) It is the same store where you do your other shopping
b) The store clerks are friendly and helpful
c) The store clerks speak your language
d) The location is safe
e) The location is convenient, easy to get to
f) The store hours are convenient
g) The store has the right sizes and brands of WIC foods
h) The prices on non-WIC items are reasonable
i) It specializes in WIC items
Page E(A)-14
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
IMPACT OF TRAINING AND COUNSELING ON BEHAVIOR
18. Let’s talk about some of the services at the WIC agency. In addition to your
scheduled appointments, have you attended any group education sessions that
were recommended to you by the WIC staff?
YES [CONTINUE]
NO [SKIP TO Q23]
19. Were any
of these
seminars
about…?
[READ]
YES
NO
20. IF YES IN
Q19, ASK:
Did the
seminar
influence you
to make any
lifestyle
changes?
YES
Nutrition or
preparing
nutritious meals?
Breastfeeding your
baby?
YES
YES
NO
NOT
YES
NO
(To Q22)
(To Q22)
Disciplining your
child?
YES
YES
NO
NOT
22. IF NO IN
Q20, ASK:
Why not?
What about
the program
or session
didn’t work
for you?
NO
YES
NOT
21. IF YES IN
Q20, ASK:
Specifically, what
changes did you
make?
(To Q22)
Eating more healthy
How to cook healthy
meals
Avoiding bad foods
OTHER [SPECIFY]
How to do it
Dealing with problems
Helping my baby to
do it
Getting my family to
accept it/cooperate
OTHER [SPECIFY]
Better parenting
Being more patient
Learning what works
OTHER [SPECIFY]
Boring, not interesting
Boring, not interesting
Boring, not interesting
Too long
Too complicated
Poor teacher
Not practical, useful
Foods I don’t eat
I already knew it
OTHER [SPECIFY]
Too long
Too complicated
Poor teacher
Not ―hands-on‖
I already knew it
OTHER [SPECIFY]
Too long
Too complicated
Poor teacher
Not realistic
I already knew it
OTHER [SPECIFY]
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OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
Educating your
child?
YES
YES
NO
NOT
(To Q22)
Living a healthy
lifestyle?
YES
NO
Smoking
cessation?
YES
NOT
YES
YES
NO
NOT
(To Q22)
(To Q22)
Accessing, or
making use of,
other social
services?
YES
YES
NO
NOT
(To Q22)
Better parenting
Being more patient
Learning what works
Learning new
techniques
OTHER [SPECIFY]
Making changes
(general)
Stopping smoking
Eating healthy
OTHER [SPECIFY]
Stopped smoking
Cut back smoking
Trying to stop smok’g
2nd
Reducing
hand
smoke for family
OTHER [SPECIFY]
Learning what they
are, what I/we qualify
for
Getting referrals
Finding out where
they’re located
Getting Food Stamps
Boring, not interesting
Boring, not interesting
Boring, not interesting
Boring, not interesting
Too long
Too complicated
Poor teacher
Too general
I already knew it
OTHER [SPECIFY]
Too long
Too complicated
Poor teacher
I already knew it
OTHER [SPECIFY]
Too long
Too complicated
Poor teacher
I already knew it
OTHER [SPECIFY]
Too long
Too complicated
Poor teacher
I already knew it
OTHER [SPECIFY]
Getting Medicaid
Getting TANF
(housing assistance)
OTHER [SPECIFY]
Why not?
Page E(A)-16
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
23. I am going to read you a list of potential benefits of the WIC program. Please
indicate how valuable they are to you by giving me a number from 0 to 5, with 5
meaning extremely valuable and 0 being not valuable to you at all. How
important is [INSERT FROM BELOW]?
Extremely valuable
Not at all valuable
5-----------4-----------3-----------2-----------1-----------0
[ROTATE START POINT]
a) Time to talk with other mothers
b) Money saved on grocery bills
c) Health information
d) Nutrition information
e) Checking blood, height and weight
f) Advice from WIC staff
g) Vouchers for foods I know are nutritious
h) Helps me stay on time with shots for my child
i) Taught me about breastfeeding
j) Taught me about the foods babies need
k) Taught me about the foods children need
l) Taught me about the foods I need
24. How much one-on-one nutrition counseling have you received in person for this
most recent pregnancy/baby? [IF R.=PREGNANT, READ: pregnancy. IF
R.=BREASTFEEDING/POSTPARTUM, READ: child]. Would you say…?
[READ UNTIL R. INDICATES ANSWER]
None at all [VERIFY: ―You received no counseling about nutrition and
healthy eating at the clinic?‖ IF AFFIRMED, SKIP TO Q30]
One session only
2-3 sessions
4-5 sessions
6-7 sessions
8 or more sessions
25. Not counting the paperwork or other processing time, how much time would you
say the actual counseling lasted, on average? [IF AN HOUR OR MORE,
VERIFY, ―Is this on average?‖]
___________ HOURS
___________ MINUTES
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VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
26. What topics do you remember talking about with the nutrition counselor?
[DO NOT READ AT FIRST--PROBE AND CHECK UNAIDED RECALL]
[THEN READ LIST TO CHECK AIDED RECALL]
UNAIDED
YES
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
Healthy weight
Fruits and vegetables
Protein
Getting enough iron
Calcium for bone health
Vitamin C
Other vitamins and food supplements
Food safety
Physical activity
Eating/preparing healthy meals
Picky eaters
AIDED
YES
NO
27. Was the nutrition counseling useful to you?
YES [CONTINUE]
NO [SKIP TO Q29]
28. Why? [DON’T READ LIST. CHECK ALL THAT APPLY.] [PROBE:
ANYTHING ELSE?] [SKIP TO Q30 AFTER QUESTION.]
LEARNED NEW THINGS
COUNSELOR SEEMED TO UNDERSTAND ME/CARE ABOUT ME
IT MOTIVATED ME TO MAKE CHANGES/HELPED ME SET GOALS
HELPED ME EAT/BE HEALTHIER
OTHER: SPECIFY __________________________
29. Why not? [DON’T READ LIST. CHECK ALL THAT APPLY.] [PROBE:
ANYTHING ELSE?]
BORING/NOTHING NEW LEARNED
REPETITIVE
LANGUAGE PROBLEMS
TOO FAST. FELT RUSHED
DISTRACTIONS (NOISE, PEOPLE, CONFUSION)
COUNSELOR DIDN’T UNDERSTAND/TAILOR TO INDIVIDUAL CONCERNS
OTHER: SPECIFY __________________________
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Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
CURRENT SITUATION & BEHAVIORS
SKIP TO Q32 IF R.=PREGNANT AND Q4= FIRST,ONLY CHILD
30. At the current time, what, if any, health insurance do you have for your child/ren?
[IF R. SAYS SOMETHING LIKE ― AETNA, BLUE CROSS/BLUE SHIELD,
KAISER, OR UNITED HEALTHCARE‖, CLARIFY WHETHER IT IS
PRIVATE INSURANCE THROUGH AN EMPLOYER OR NOT. IF MORE
THAN ONE GIVEN, ASK FOR MAIN ONE.]
NONE
MEDICAID
STATE CHIP – CHILDREN’S HEALTH INSURANCE PROGRAM
OTHER STATE PROGRAM
MILITARY/TRICARE
PRIVATE INSURANCE THROUGH AN EMPLOYER
PRIVATE INSURANCE NOT THROUGH AN EMPLOYER (I.E. THEIR OWN INSURANCE)
OTHER: PLEASE SPECIFY: ___________________
31. What, if any health insurance, do you have for yourself? [IF MORE THAN ONE
GIVEN, ASK FOR MAIN ONE.]
NONE
MEDICAID
OTHER STATE PROGRAM
MILITARY/TRICARE
PRIVATE INSURANCE THROUGH MOTHER/SPOUSE’S EMPLOYER (E.G. MILITARY)
PRIVATE INSURANCE NOT THROUGH MOTHER/SPOUSE’S EMPLOYER
OTHER: PLEASE SPECIFY: ___________________
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OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
32. Are you, or members of your family, getting food through the… [READ LIST]?
a) Food Stamp program, also known as [INSERT
FROM P6c]?
b) Free or reduced price School Lunch or Breakfast
program?
c) Summer Food Service program, for kids when not in
school?
d) Food Distribution Program on Indian Reservations
(FDPIR)?
e) Temporary Emergency Food Assistance program?
f) Child and Adult Care Food program, which provides
free lunches for children at day care centers?
g) Local/community food bank or pantry?
h) Commodity Supplemental Food Program, which
provides food packets that are distributed through
State and local agencies? [IF Q32h=YES, SKIP TO
Q33]
YES
NO
i) Have you ever participated in Commodity Supplemental Food Program in the
past?
YES
NO [SKIP TO Q33]
j) How long ago did your participation in that program stop?
_____________ YEARS AGO
_____________ MONTHS AGO
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Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
33. Now thinking about how your family eats generally, which of the following
statements best describes the food you had to eat in your household during the last
12 months? Did your household… [READ LIST]? [CHECK ONE ONLY]
Have enough to eat [SKIP TO Q35]
Sometimes do not have enough to eat, or
Often not have enough to eat
34A. Now I am going to read a series of statements that people sometimes make about food
and meals. For each statement, tell me if the statement was often, sometimes or never true
for you in the last 12 months. [REPEAT SCALE AS NECESSARY]
1) We worried whether our food would run out
before we got money to buy more.
OFTEN SOMETIMES NEVER TRUE
2) The food that we bought just didn’t last and
we didn’t have money to get more.
3) We couldn’t afford to eat balanced meals.
OFTEN SOMETIMES NEVER TRUE
OFTEN SOMETIMES NEVER TRUE
IF R.=PREGNANT AND Q4=FIRST, ONLY
CHILD, SKIP TO Q34b.
4) We relied on only a few kinds of low-cost
food to feed our children because we were
running out of money to buy food.
OFTEN SOMETIMES NEVER TRUE
5) We couldn’t feed our children a balanced
meal, because we couldn’t afford that.
OFTEN SOMETIMES NEVER TRUE
6) The children were not eating enough
because we just couldn’t afford enough food.
OFTEN SOMETIMES NEVER TRUE
34B. In the last 12 months, did you or other adults in the
YES
household ever cut the size of your meals or skip
NO [SKIP TO Q34C]
meals because there wasn’t enough money for food?
1) How often did this happen— almost every
ALMOST EVERY MONTH
month, some months but not every month, or
SOME MONTHS BUT NOT EVERY MONTH
in only 1 or 2 months?
ONLY 1 OR 2 MONTHS
34C. In the last 12 months, did you ever eat less than you
felt you should because there wasn’t enough money
for food?
YES
NO
34D. In the last 12 months, were you ever hungry, but
didn’t eat, because there wasn’t enough money for
food?
YES
NO
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VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
YES
34E. In the last 12 months, did you lose weight because
NO
there wasn’t enough money for food?
34F. In the last 12 months, did you or other adults in your
YES
household ever not eat for a whole day because there
NO [SKIP TO Q34H.]
wasn’t enough money for food?
34G. How often did this happen— almost every ALMOST EVERY MONTH
month, some months but not every month, or in
SOME MONTHS BUT NOT EVERY MONTH
only 1 or 2 months?
ONLY 1 OR 2 MONTHS
SKIP TO Q42 IF R.=PREGNANT AND Q4=THIS IS FIRST,ONLY CHILD]
[USE ―child‖ INSTEAD OF CHILDREN IN Q35H-L IF R.=BREASTFEEDING/
POSTPARTUM AND Q4=FIRST, ONLY CHILD]
34H. In the last 12 months, did you ever cut the size of any
YES
of the children’s meals because there wasn’t enough
NO
money for food?
34I. In the last 12 months, were the children ever hungry
YES
but you just couldn’t afford more food?
NO
34J. In the last 12 months, did any of the children ever
YES
skip a meal because there wasn’t enough money for
NO
food?
34K. How often did this happen— almost
ALMOST EVERY MONTH
every month, some months but not every
SOME MONTHS BUT NOT EVERY MONTH
month, or in only 1 or 2 months?
ONLY 1 OR 2 MONTHS
34L. In the last 12 months, did any of the children ever
YES
not eat for a whole day because there wasn’t enough
NO
money for food?
IF R.=BREASTFEEDING/POSTPARTUM AND Q4=THIS IS FIRST,ONLY CHILD,
THEN SKIP TO Q38.
35. You said you have [READ NUMBER FROM Q4] other children in addition to
the baby [FOR PREGNANT ADD: that is coming]. Of these other children, how
many were breastfed, even if only for a short time?
[RECORD NUMBER. NUMBER CAN NOT EXCEED NUMBER FROM Q4.
IF Q35= 0, SKIP TO Q36d]
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VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
36. Did you breastfeed after the last baby before this one, even if only for a short
time?
YES [GO TO Q36a ]
NO [GO TO Q36d) ]
a) For how long
did you breastfeed that baby?
(Probe if needed)
b) Of that time,
how much of that
time was the baby
exclusively
breastfed, with no
other food?
____<2 wks
[SKIP TO Q36d]
____ NUMBER OF
WEEKS OR
MONTHS (―99‖ IF
DON’T KNOW)
____ NUMBER OF
WEEKS OR
MONTHS (―99‖ IF
DON’T KNOW)
____ [1] WEEKS
[2] MONTHS
[9] DOESN’T
KNOW
____ [1] WEEKS
[2] MONTHS
[9] DOESN’T
KNOW
c) Why did you stop
breastfeeding? [AFTER
d) Why did you not
breastfeed? [ AFTER
THIS QUESTION, SKIP
THIS QUESTION, SKIP
TO Q42 IF
TO Q42 IF
R.=PREGNANT; OR TO
R.=PREGNANT]
Q38 IF
R.=BREASTFEEDING
OR POSTPARTUM
[DO NOT READ. CHECK
[DO NOT READ. CHECK ALL
ALL THAT APPLY]
THAT APPLY]
HEALTH ITEMS
HEALTH ITEMS
1. Baby had difficulty
1. Baby had difficulty
nursing
nursing
2. Not producing enough
2. Not producing enough
breast milk
breast milk
3. Baby not gaining
3. Baby not gaining
enough weight
enough weight
4. Nipples sore, cracked
4. Nipples sore, cracked or
or bleeding
bleeding
5. Mother or baby became 5. Mother or baby became
sick
sick
TIME/DUTY
99 DITEMS
TIME/DUTY ITEMS
6. OtherOchildren to take
6. Other children to take
care ofN
care of
7. Went ’back to work or
7. Went back to work or
schoolT
school
8. Wanted my body back
8. Wanted my body back to
to myself
K
myself
9. Wanted/needed
N
9. Wanted/needed
someone
O else to feed
someone else to feed
the baby
W
the baby
10. Too many household
10. Too many household
duties
duties
PREFERENCE ITEMS
PREFERENCE ITEMS
11. Did not like
11. Did not like
breastfeeding
breastfeeding
12. Did not want to be tied
12. Did not want to be tied
down
down
13. Embarrassment
13. Embarrassment
14. Husband/partner did not 14. Husband/partner did not
want me to breastfeed
want me to breastfeed
15. Felt it was the right time 15. Felt it was the right time
to stop
to stop
Page E(A)-23
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
FOR BREASTFEEDING AND POSTPARTUM ONLY:
38. Now, do you or did you breastfeed your most recent baby, even if only for a short
time?
YES
NO [GO TO Q39d ]
39. Is it still ongoing or did you stop breastfeeding? [DO NOT READ ANSWERS]
ONGOING [SKIP TO 44]
STOPPED
a) For how long
did the breastfeeding last in
total?
(Probe if needed)
b) Of that time, how
much of that time
was the baby
exclusively breastfed,
with no other food?
____ <2 wks
[SKIP TO Q39c]
____ NUMBER OF
WEEKS OR
MONTHS (―99‖ IF
DON’T KNOW)
____ [1] WEEKS
[2] MONTHS
[9] DOESN’T
KNOW
____ NUMBER OF
WEEKS OR MONTHS
(―99‖ IF DON’T KNOW)
____ [1] WEEKS
[2] MONTHS
[9] DOESN’T
KNOW
c) Why did you stop
breastfeeding? [AFTER
THIS QUESTION, SKIP
TO Q40]
d) Why did you not
breastfeed?
DO NOT READ. CHECK ALL
DO NOT READ. CHECK ALL
THAT APPLY]
THAT APPLY]
HEALTH ITEMS
HEALTH ITEMS
1. Baby had difficulty
1. Baby had difficulty
nursing
nursing
2. Not producing enough
2. Not producing enough
breast milk
breast milk
3. Baby not gaining
3. Baby not gaining
enough weight
enough weight
4. Nipples sore, cracked or
4. Nipples sore, cracked or
bleeding
bleeding
5. Mother or baby became sick 5. Mother or baby became sick
TIME/DUTY ITEMS
TIME/DUTY ITEMS
6. Other children to take care 6. Other children to take care
of
of
7. Went back to work or
7. Went back to work or
school
school
8. Wanted my body back to
8. Wanted my body back to
myself
myself
9. Wanted/needed someone
9. Wanted/needed someone
else to feed the baby
else to feed the baby
10. Too many household duties 10. Too many household duties
PREFERENCE ITEMS
PREFERENCE ITEMS
11. Did not like breastfeeding
11. Did not like breastfeeding
12. Did not want to be tied
12. Did not want to be tied down
down
13. Embarrassment
13. Embarrassment
14. Husband/partner did not
14. Husband/partner did not
want me to breastfeed
want me to breastfeed
15. Felt it was the right time to
15. Felt it was the right time to
stop
stop
Page E(A)-24
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
40. What, if anything, might have helped you to breastfeed? [AFTER QUESTION, SKIP
TO Q44]
1.
2.
3.
4.
5.
6.
7.
8.
9.
HELP BABY THAT HAD TROUBLE NURSING
SHOW ME WAYS TO MAKE IT HURT LESS
SHOW ME WAYS TO MAKE IT EASIER
SHOW ME HOW TO PUMP MILK
TALK TO UNSUPPORTIVE HUSBAND/PARTNER
TALK TO UNSUPPORTIVE MOTHER/GRANDMOTHER
TELL ME HOW TO WORK IT INTO MY SCHEDULE
NOTHING
OTHER [SPECIFY] _____________________________
41. What one thing might have helped you breastfeed for a longer period of time?
[AFTER QUESTION, SKIP TO Q44]
1.
2.
3.
4.
5.
6.
7.
8.
9.
HELP BABY THAT HAD TROUBLE NURSING
SHOW ME WAYS TO MAKE IT HURT LESS
SHOW ME WAYS TO MAKE IT EASIER
SHOW ME HOW TO PUMP MILK
TALK TO UNSUPPORTIVE HUSBAND/PARTNER
TALK TO UNSUPPORTIVE MOTHER/GRANDMOTHER
TELL ME HOW TO WORK IT INTO MY SCHEDULE
NOTHING
OTHER [SPECIFY] _____________________________
FOR PREGNANT ONLY:
42. With your upcoming baby, are you planning to breastfeed?
YES [CONTINUE]
NO [SKIP TO Q44]
43. For how many months in total from the baby’s birth, are you planning to breastfeed?
________ MONTHS (―99‖ IF DOESN’T KNOW)
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Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
FOR EVERYONE:
44. What, if any, advantages do you see of breastfeeding? [UNAIDED AWARENESS.
DO NOT READ. CHECK ALL THAT APPLY] [PROBE: ANYTHING ELSE?]
BETTER/HEALTHIER BABY
MOTHER-BABY BONDING, CLOSENESS
BREASTFEEDING ENJOYABLE
EASIER, MORE CONVENIENT
CHEAPER/PROVIDED FOR FREE
FRIENDS/FAMILY ARE FAMILIAR WITH IT AND CAN HELP ME
OTHER: SPECIFY ______________________________
45. What, if any, disadvantages do you see of breastfeeding? [UNAIDED
AWARENESS. DO NOT READ. CHECK ALL THAT APPLY] [PROBE:
ANYTHING ELSE?]
NOT ENOUGH BREAST MILK TO SATISFY BABY
HARD TO DO WHEN ONE IS GOING BACK TO WORK OR SCHOOL
PAIN OR DISCOMFORT
NO ONE ELSE CAN FEED THE BABY
TOO TIME-CONSUMING
TOO MUCH WORK COMPARED TO FORMULA
MORE EXPENSIVE COMPARED TO FORMULA
FRIENDS/FAMILY ARE NOT FAMILIAR WITH IT CANNOT HELP ME
OTHER: SPECIFY ______________________________
FRIENDS
46. Do you have friends who you think are eligible for WIC but who haven’t applied for
WIC benefits?
YES
NO
47. Do you know anyone who was in WIC but dropped out before their certification
period was over?
YES
NO
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Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
48. What, do you think, are the main reasons that people don’t participate in WIC?
PROBE: Anything else? [DO NOT READ. CODE UP TO THREE REPLIES.]
LACK OF TRANSPORTATION TO CLINIC, TRANSPORTATION DIFFICULTIES
THEY DON’T KNOW THAT WIC EXISTS
INCONVENIENT HOURS/DAYS CLINIC OPEN
SERVICES (INCLUDING WAITING TIME) TAKE TOO MUCH TIME
WAITING SPACE AT CLINIC IS LIMITED
LACK OF CHILD CARE
LANGUAGE BARRIERS
PROBLEMS QUALIFYING FOR BENEFITS
DIFFICULTIES KEEPING APPOINTMENT TIMES
WIC FOOD SELECTION NOT DESIRABLE
WIC FOOD STORES NOT CONVENIENT (HOURS OR LOCATION)
WIC FOOD HARD TO FIND ON SHELVES (BRANDS, QUANTITIES)
IMMIGRATION CONCERNS
DIDN’T NEED FOOD BENEFIT
OTHER: PLEASE SPECIFY______________________________
DEMOGRAPHICS
We’re almost done with this survey. I’d like to ask a few questions for classification
purposes only.
SKIP IF RECORDED IN PART 1: P2h
49. Are you … [READ]
Hispanic or Latino?
Not Hispanic or Latino?
REFUSED
SKIP IF RECORDED IN PART 1: P2i
50. How would you characterize yourself in terms of race? [READ ALL. CHECK AS
MANY AS APPLY]
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
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Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
51. What is the highest level of education you have attained? [READ UNTIL R.
INDICATES ANSWER]
Refused
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
52. What is your first language, that is, the language you speak at home?
English
Arabic
Cambodian
Cantonese/ Mandarin
Farsi
French/Creole
Fulani
Hindi
Hmong
Khmer
Korean
Laotian
Punjabi
Russian
Somali
Spanish
Swahili
Tamil
Tagalog
Urdu
Vietnamese
Other: SPECIFY
_________
IF R. HAS NOT BEEN CHOSEN FOR IN-HOME AUDIT, READ:
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.
Page E(A)-28
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Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
PART 3: TELEPHONE SCREENER FOR IN-HOME AUDIT (Version A)
IF R. HAS BEEN CHOSEN FOR IN-HOME AUDIT, READ:
Thank you so much for your help in answering this survey. Your feedback, combined with
other confidential responses, will really help improve the WIC program.
SCREENER
SA. Our contract with USDA’s WIC asks us to randomly select half of the people who
complete the telephone survey to see if we can ask you some additional questions at your
home. This would take 30 minutes or less and you would receive $20 for your time.
Again, your answers will be confidential and not have any effect on benefits, either good
or bad. The purpose of the in-home interview would be to ask about who makes up your
family group and to understand more about your family’s income and expenses -- as a
way of better understanding people’s needs…
Is there a time you would be available? For example, would you be free at…
[INTERVIEWER SET TIME/DATE]?
TIME: ________AM/PM
DATE: _______________
SB.
YES [SKIP TO SD]
NO, NOT FREE AT THAT TIME [SKIP TO SC]
NO, REFUSAL [CONTINUE]
Can I ask why you don’t want to participate? While the in-home interview is voluntary,
it only takes a bit of your time and is a great way to make $20, paid in cash, Again, your
responses will be anonymous and will not affect your WIC benefits in any way. We can
set a time that works with your schedule.
Page E(A)-29
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
SC.
When would be a good time for you?
TIME: ________AM/PM
DATE: _______________
[IF REFUSAL, ENTER ―0‖ FOR TIME AND DATE]
SD.
LET R. SUGGEST TIME/DATE AND NEGOTIATE AS INTERVIEWER’S
SCHEDULE PERMITS. THEN SKIP TO SD
IF R. STILL REFUSES, ASK THE FOLLOWING QUESTION: I’m sorry you don’t
wish to participate in the study. For statistical purposes only, I need to know if you
still live at [READ ADDRESS FROM P1], or if you have moved?
NOT MOVED [THANK & TERMINATE]
MOVED [ASK: Do you now live in another state?]
a. YES [THANK & TERMINATE]
b. NO [CONTINUE]
When you changed addresses, did you also have to use a new WIC agency or could
you use the same one as before?
a. NEW AGENCY [THANK & TERMINATE]
b. SAME AGENCY AS BEFORE [THANK & TERMINATE]
Great. Let me just confirm your address and telephone number(s).
READ ADDRESS & TELPHONE NUMBER ON FILE. IF ADDRESS IS
CORRECT MOVE TO SE. IF DIFFERENT SAY:
IS THIS INFORMATION CORRECT?
YES [IF YES, SKIP TO SE]
NO
1) I see that you’ve moved. When you moved, did you [READ]:
Move within the same area so that you could use the same WIC
agency or
Move to a different area with a new WIC agency?
SE.
ASK: Is there a second telephone number where you can also be reached?
YES [PHONE NUMBER: ___________________]
NO
IF YES, RECORD IT.
SF.
TELL RESPONDENT YOU WILL CONFIRM THE APPOINTMENT A DAY OR
TWO AHEAD OF TIME AND MAKE SURE THEY ARE IN ACCORD.
Page E(A)-30
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
IN-HOME AUDIT [INTERVIEWER WILL CARRY MACRO IDENTIFICATION]
Public reporting burden for this collection of information is estimated to average 24 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. Hi. Thanks for agreeing to do the second part of our survey. Your answers are completely confidential
and, as I mentioned when we set this up, nothing you say will have any bearing on your benefits. The
WIC program is just trying to get a better idea of who participates in the program and their
circumstances. At the end, I will be giving you $20 in appreciation of your time.
IDENTITY AND RESIDENCY
2. The first thing we need is some identification—silly as it may seem—and proof that you live here. [IF
R. HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF ID
AND RESIDENCY PROOF FROM LIST.]
Identification proofs [CHECK AT LEAST ONE]
State-issued license or ID
U.S. passport w/photo
Foreign passport w/photo
WIC folder
W-2 form or Tax bill w/name
Birth certificate
Social Services letter w/ name
Social Security or Green card
Hospital or immunization record
Other: SPECIFY ________________
Residency proofs [CHECK AT LEAST ONE]
State-issued license or ID w/address
Other: SPECIFY ________________
State/federal correspondence w/address
WIC folder
Checkbook w/address
Rent or mortgage receipt, lease w/address
Utility or tax bill w/address
Documents from public school w/address
Written statement from reliable third party
(e.g. non-profit aid organization)
PRIMARY FAMILY/ECONOMIC UNIT
3. Let’s begin by having you tell me the names of all the persons who live or stay with you whether they
are related to you or not. I will type in the names so I can follow up with some questions. [PROBE:
ANYONE ELSE?]
RECORD ALL NAMES IN LIST FORM.
1)
2)
3)
4)
_____________________________
_____________________________
_____________________________
ETC.
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Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
AFTER ALL PERSONS ARE LISTED, ASK FOLLOWING QUESTIONS FOR EACH PERSON:
4. What is their relationship to [SAY You OR NAME 1. Spouse
11. Uncle/aunt
OF SAMPLED PARTICIPANT IF DIFFERENT]?
2. Partner
12. Cousin
3. Child
13. Nephew/niece
4. Step-child
14. Parent-in-law
5. Foster child
15. Brother-in-law/sister-in-law
6. Parent/ Guardian
16. Other relative
7. Step-parent
17. Other non-relative
8. Foster parent
18. Child in Temporary Care
9. Brother/Sister
of Friends/Relatives
10. Grandparent
5. Is this individual male or female?
1-Male
2-Female
6. How old is this person?
_____ YEARS
7. FOR ANY CHILD LESS THAN 5 YEARS OR ANY WOMAN GREATER
1-Yes
THAN 14 YEARS ASK: Is this person receiving WIC now?
2-No
8. OTHERWISE, IF Q6≥15, ASK: Do you consider [READ NAME] to be part
of your family group -- that is, you are sharing income and expenses as if
you were a family -- OR do you feel that you each keep your income and
expenses and food separately?
1-Share like family
2-Separate finances
IF Q6<15, ASK: Do you consider [READ NAME] to be part of your family
group -- that is, you are responsible for taking care of them as if you were
all in the same family?
9. PROGRAM WILL CALCULATE NUMBER OF PEOPLE IN PRIMARY
NUMBER OF PEOPLE
ECONOMIC UNIT
IN PRIMARY
[Q4=1,2,3, 4 OR 5] or [Q8=1] and [Q6≥15]
ECONOMIC UNIT
10. COMPUTER WILL COMPARE THE NUMBER OF PEOPLE IN PRIMARY ECONOMIC UNIT (Q9) WITH #
OF HOUSEHOLD MEMBERS IN WIC RECORDS (P5-TOTAL IN PRIMARY ECONOMIC UNIT).
IF Q9=P5, SKIP TO Q11
IF Q9P5, SAY: The WIC records show that back in [INSERT MONTH/DATE OF CERTIFICATION] you
had [INSERT #] adults and [INSERT #] children in this household, which is fewer than we have listed
here. Can I verify that everyone on our list here IS part of your main family unit? [PROBE & DELETE
NAMES OR INFORMATION IN Q2-9 AS APPROPRIATE]
NOTE: IF RESPONDENT HAS DIFFICULTY RECALLING TIME PERIOD USE NARRATIVE APPROACH
IN WHICH A TIME IS LINKED TO A SALIENT EVENT]
FROM PRIMARY ECONOMIC UNIT LIST, COMPUTER WILL GENERATE A LIST OF ―POTENTIAL
WAGE EARNERS‖ – DEFINED AS ALL THE ADULTS AND ALL CHILDREN > 15 YEARS
Page E(A)-32
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
ADJUNCTIVE OR AUTOMATIC ELIGIBILITY
11. [SKIP TO Q12 IF P3c=NO (i.e., no adjunctive eligibility)] The WIC records show that you qualified for
WIC because you, or a member of your family, participate in the [FILL IN FROM P4] program. Can you
quickly show me a document that demonstrates your or their participation in that program such as the
certification card, the award letter you got, or an active program voucher? [IF NO, PROBE: Do you
have anything at all? AND EVALUATE WHAT THEY COME UP WITH. MARK YES OR NO BOX
BELOW AND CONTINUE]
YES, PROOF SHOWN – ENTER :
a) NAME OF PROGRAM RECIPIENT ON
PROOF SHOWN.
[MAKE SURE IT MATCHES SOMEONE
___________________________
IN THE PRIMARY ECONOMIC UNIT;
OTHERWISE ASK FOR ANOTHER
DOCUMENT/CARD AS PROOF]
b) DATE OF DOCUMENT/CARD
[TYPE IN]______________________
ISSUANCE (MM/DD/YYYY)
99 NO DATE [PROBE: Do you have anything that
shows the dates for your participation in the program? IF
NO ASK FOR DATE OF FIRST ELIGIBILITY.]
c) DATE OF DOCUMENT/CARD OR
[TYPE IN]______________________
ELIGIBILITY EXPIRATION
99 NO DATE [PROBE: Do you have anything that shows
(MM/DD/YYYY)
the expiration date?]
d) NAME OF ISSUING AGENCY
[TYPE IN]______________________
99
NOT EVIDENT [PROBE: Do you have anything that
shows the agency name?]
e) NUMBER ON DOCUMENT/CARD
f) DOCUMENT/CARD SHOWN
[TYPE IN]______________________
99 NO NUMBER
Certification card [SKIP TO Q13]
Award letter [SKIP TO Q13]
Active program voucher [SKIP TO Q13]
Food Stamp EBT card [SKIP TO Q13]
Other [IF ANY DOUBTS ABOUT VALIDITY, HAND
R. MACRO DISCLOSURE FORM TO FILL OUT
AND SIGN. REFER TO PRECODED QUESTION P4
AND USE R-7 FOR TANF; R-1 FOR FOOD
STAMPS/ MEDICARE]
NO, PROOF NOT SHOWN OR WRONG PROOF SHOWN. HAND R. MACRO DISCLOSURE
FORM AND HAVE THEM FILL IT OUT AND SIGN IT. FORMS TO USE ARE LISTED.
[CONTINUE TO Q12]
R-7 TANF [NOTE: R- # FORMS ARE MACRO’S INFO RELEASE FORMS]
R-1 FOOD STAMPS, MEDICAID, CHILDREN’S MEDICAID OR CHIP
Page E(A)-33
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
INCOME ELIGIBILITY
12. Now I am going to ask you about the income earned by you and other primary members of this
household. WIC is interested in the accuracy of their data records in this area. The information you
share with me will be confidential and will be combined with that from other people, so WIC won’t know
your or anybody else’s personal information.
So let’s start with [READ NAME OFF LIST OF PRIMARY ECONOMIC UNIT. RESPONDENT
SHOULD BE FIRST ON LIST.]
[NOTE: IF RESPONDENT HAS DIFFICULTY RECALLING TIME PERIOD USE NARRATIVE
APPROACH IN WHICH A TIME IS LINKED TO A SALIENT EVENT]
a) Thinking back to [INSERT MOST
RECENT CERTIFICATION
MONTH/YEAR], did [INSERT
you/NAME] receive any income
from… [READ FROM BELOW]?
CHECK ONLY IF YES
Wages, salary, fees
(excluding military pay)
YES
NO
b) FOR EACH ITEM CHECKED c) Can you show me some
IN a), ASK: How much did
evidence of that income
[INSERT you/NAME] earn?
such as [READ FROM
LIST ACCOMPANYING
EACH ITEM]
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
$_______ Other: _____
Military pay
YES
NO
$_______
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Pay stub/earnings
statement
W-2 form
2007 IRS tax return
Other: _____
None: GIVE FORM R-3,
WHICH WILL COLLECT
INFO ON:
- POSITON HELD
- FIELD OF WORK
-HOURS/WEEK
-ZIP CODE
FOR USE IN DETERMINING
AVERAGE WAGE IN AREA
Leave and earnings
statement
Other: _____
None: GIVE FORM R-5
Page E(A)-34
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
W-2 form
Other: _____
None
$_______
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Business records
Expense receipts
Other: ______
None
$_______
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other:_____
2007 IRS tax return
Copy of check, check
stub
Letter of determination
Other: _____
None
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Copy of check, check
stub
Award statement
Statement from
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Copy of check
Support agreement
Divorce/separation
Tips and bonuses
YES
NO
$_______
Net income from self
employment (from farm and
non-farm business)
YES
NO
Unemployment compensation
YES
NO
Workers compensation
YES
NO
$_______
Child Support
YES
NO
$_______
Alimony
YES
NO
$_______
insurance company
Other: _____
None
Copy of check
Support agreement
Divorce/separation
decree
Court order
Other: _____
None: GIVE FORM R-6
decree
Court order
Other: _____
None: GIVE FORM R-6
Page E(A)-35
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
SSA Award letter
Statement of benefits
2007 IRS tax return (line
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Notice of benefits
Copy of check, check
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Notice of benefits
Copy of check, check
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _______
Notice of benefits
Copy of check, check
Notice of benefits
Copy of check, check
$_______
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Notice of benefits
Copy of check, check
$_______
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Social Security
YES
NO
$_______
SSI – Fed government
YES
NO
$_______
SSI—State issued
YES
NO
$_______
Any private or public
pension, annuity or survivor’s
benefits
YES
NO
$_______
Medical assistance (any)
YES
NO
Veteran’s payments
YES
NO
14a on 1040A)
Other: _____
None
stub
Other: _____
None
stub
Other: _____
None
stub
Other: _____
None: GIVE FORM R-1
stub
Other: _____
None: GIVE FORM R-1
stub
Other: _____
None: GIVE FORM R-1
Page E(A)-36
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
Other cash income
YES
NO
$_______
Energy assistance
YES
NO
$_______
Net rental income
YES
NO
$_______
Income from trusts
YES
NO
$_______
Commissions
YES
NO
$_______
Income from estates
YES
NO
$_______
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Benefits statement
Copy of check, check
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Business records
Expense receipts
Other: ______
None
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Business records
Expense receipts
Other: ______
None
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Business records
Expense receipts
Other: ______
None
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Business records
Expense receipts
Other: ______
None
stub
Other: _____
None: GIVE FORM R-1
Notice of benefits
Other: _____
None: GIVE FORM R-1
Page E(A)-37
OMB Number: 0584-0484
Expiration Date: XX/XX/20XX
VERSION A: PREGNANT, BREASTFEEDING OR POSTPARTUM 2-20-09
Net royalties
YES
NO
$_______
Interest or dividends
YES
NO
$_______
Regular contributions from
persons not in household
YES
NO
$_______
Other: SPECIFY
__________________
YES
NO
$_______
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Business records
Expense receipts
Other: ______
None
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
2007 IRS tax return
Earnings statement
Copy of check, check
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Per week
Per 2 weeks
2 Times a month
Month
Quarter
Year
Other: _____
Copy of check, check
stub
Other: ______
None
stub
Letter of intent
Other: ______
None: GIVE FORM R-15
2007 IRS tax return
Benefits statement
Other: ______
None
REPEAT INCOME QUESTIONS (Q12) FOR EVERY ADULT MEMBER OF PRIMARY ECONOMIC UNIT.
CLOSING
13. READ: This completes our survey. It was great talking to you. Thank you so much for helping us out.
Here is $20 in appreciation for your time. [FILL OUT RECEIPT FOR INCENTIVE AND GET
SIGNATURE.]
Do you have any questions before I leave?
Have a great day/evening.
Page E(A)-38
| File Type | application/pdf |
| Author | Walter.N.Rives |
| File Modified | 2009-02-23 |
| File Created | 2009-02-20 |