National Survey of WIC Participants

National Survey of WIC Participants II

APPENDIX E(B) - INFANTS CHILDREN 2-20-09

National Survey of WIC Participants

OMB: 0584-0484

Document [pdf]

Download: pdf | pdf

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

VERSION B: INFANTS & CHILDREN 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
 Child
 Infant
b. Parent/Guardian
Name: __________________
Address: ________________
________________
c. Start date of current certification for this child (MM/DD/YYYY). [SHOULD
BE PRIOR TO JULY 31, 2008]
_____ / _____ /_____
d. Start date of original certification for this child. [MAY BE SAME AS P2c OR
EARLIER.] (MM/DD/YYYY)
_____ / _____ /_____
e. THIS QUESTION NUMBER DELIBERATELY SKIPPED
f. Birth date of child (MM/DD/YYYY)
_____ / _____ /_____ /

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

VERSION B: INFANTS & CHILDREN 2-20-09

g. Gender of child
 Male
 Female
h. Is the child …? [IF IN RECORDS. OTHERWISE ASK IN Q49AT END OF
SURVEY]
 Hispanic or Latino?
 Not Hispanic or Latino?
 Not indicated in records (COMPLETE Q49)
i. Race/ethnicity of child [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
P3.










Hmong
Khmer
Korean
Laotian
Portuguese
Punjabi
Russian
Somali









Spanish
Swahili
Tamil
Tagalog
Urdu
Vietnamese
Other: SPECIFY
_________

DO THE 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








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

VERSION B: INFANTS & CHILDREN 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

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

VERSION B: INFANTS & CHILDREN 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
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

Adults counted
in WIC family/
economic unit
who are…
(WRITE #)
N/A
N/A
N/A
N/A
N/A

Infants &
children (<15
yrs) counted in
WIC family/
economic unit
who are…
(WRITE #)
N/A
N/A
N/A
N/A
N/A

How many of total -from columns one
and two -- receive
WIC?
(WRITE #)
N/A
N/A
N/A
N/A
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

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

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

VERSION B: INFANTS & CHILDREN 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]

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

VERSION B: INFANTS & CHILDREN 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
[FROM P1A]

_____________________

______________________

 VERSION B, USE IF Q-SA (SAMPLED CHILD) AND Q-SB (PERSON
INTERVIEWED) ARE DIFFERENT. THIS WILL BE ANY INFANT AND
CHILD THAT IS SAMPLED.

 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

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

VERSION B: INFANTS & CHILDREN 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 WIC
participants, including yourself, all around the country. Your child’s 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 child’s
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.

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

VERSION B: INFANTS & CHILDREN 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 and the process you went
through to receive benefits. Is this the first time you’ve received WIC benefits for
your child or has your child participated before.
 NEW TO WIC [SKIP TO Q3]
 PARTICIPATED BEFORE [CONTINUE]

How many times has your child participated before? [ASK, THEN SKIP TO Q4]
1
2
 3 or more

2a.

How old was your child when he/she first started getting WIC benefits [ASK,
THEN SKIP TO Q4]
 At birth
 _____(# of) Months (0 to 23 months)
 _____(# of) Years (24 months or more)

Why didn’t your child 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
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OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

VERSION B: INFANTS & CHILDREN 2-20-09

 SERVICES (INCLUDING WAITING TIME) TAKE TOO MUCH TIME
 WAITING SPACE AT CLINIC IS LIMITED
 LACK OF CHILD CARE
 LANGUAGE BARRIERS
 PROBLEMS QUALIFYING FOR BENEFITS
 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______________________________
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

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

VERSION B: INFANTS & CHILDREN 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)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
9.

Customer friendliness of the WIC staff
Quality of service you get
Helpfulness of the staff
Staff’s ability to speak your language
Safety of the clinic’s location
Convenience of the clinic’s location for you
Convenience of its operating hours
Amount of time you must wait until you are seen by WIC staff
Size and space of the waiting area
Activities provided to occupy children while you wait
Way they handle paperwork for certification
How they deliver your food -[INSERT WORD USED IN P6b]

Now, think about the food benefits that you receive for your child. 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 your child likes 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 your
child for some reason?
 YES [CONTINUE]
 NO [SKIP TO Q12]

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

VERSION B: INFANTS & CHILDREN 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 ____________

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

VERSION B: INFANTS & CHILDREN 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 child’s WIC
food [INSERT WORD USED IN P6b]? [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 child’s
WIC shopping.‖
 EXCELLENT
 VERY GOOD
 GOOD
 FAIR
 POOR
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OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

VERSION B: INFANTS & CHILDREN 2-20-09

15. Do you buy your child’s 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

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

VERSION B: INFANTS & CHILDREN 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]

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

21. IF YES IN
Q20, ASK:
Specifically, what
changes did you
make?

22. IF NO IN Q20,
ASK: Why not?
What about the
program or session
didn’t work for you?













Boring, not interesting









Boring, not interesting









Boring, not interesting

(To Q22)







(To Q22)




Disciplining your
child?

YES




(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]

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 B: INFANTS & CHILDREN 2-20-09

Educating your
child?

YES




(To Q22) 


Living a healthy
lifestyle?


YES
NO

Smoking
cessation?

YES
NO

YES


(To Q22) 




(To Q22) 


Accessing, or
making use of,
other social
services?


YES

YES

(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]

Getting Medicaid
Getting TANF
(housing assistance)
OTHER [SPECIFY]

Why not?

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

VERSION B: INFANTS & CHILDREN 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 your child 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
child?

 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

Page E(B) - 16

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

VERSION B: INFANTS & CHILDREN 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 __________________________

Page E(B) - 17

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

VERSION B: INFANTS & CHILDREN 2-20-09

CURRENT SITUATION & BEHAVIORS
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: ___________________
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








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
Page E(B) - 18

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

VERSION B: INFANTS & CHILDREN 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 Q38]
 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.
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
OFTEN SOMETIMES NEVER TRUE
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

34E. In the last 12 months, did you lose weight because
there wasn’t enough money for food?

YES
 NO
Page E(B) - 19

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

VERSION B: INFANTS & CHILDREN 2-20-09

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
34H. In the last 12 months, did you ever cut the size of any
of the children’s meals because there wasn’t enough
money for food?
34I. In the last 12 months, were the children ever hungry
but you just couldn’t afford more food?

YES
 NO
YES
 NO

34J. In the last 12 months, did any of the children ever skip YES
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?

Page E(B) - 20

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

VERSION B: INFANTS & CHILDREN 2-20-09

38. Was this child ever breastfed, even if only for a short time?
 YES
 NO [GO TO Q39d ]
39. Is it still ongoing or has the breastfeeding stopped? [DO NOT READ ANSWERS]
 ONGOING [SKIP TO 44]
 STOPPED
a) For how long
b) Of that time, how
c) Why did was
d) Why was the child not
did the breastmuch of that time
breastfeeding stopped?
breastfed?
feeding last in
was the baby
[AFTER THIS
total?
exclusively breastfed, QUESTION, SKIP TO
with no other food?
Q41]
____ <2 wks
[SKIP TO Q39c]
____ NUMBER OF
WEEKS OR
MONTHS (―99‖ IF
DON’T KNOW)
____ [1] WEEKS
[2] MONTHS
[9] DON’T
KNOW

____ NUMBER OF
WEEKS OR MONTHS
(―99‖ IF DON’T KNOW)
____ [1] WEEKS
[2] MONTHS
[9] DON’T
KNOW

[DO NOT READ. CHECK ALL
THAT APPLY]
HEALTH ITEMS
1. Baby had difficulty
nursing
2. Not producing enough
breast milk
3. Baby not gaining enough
weight
4. Nipples sore, cracked or
bleeding
5. Mother or baby became
sick
TIME/DUTY ITEMS
6. Other children to take
care of
7. Went back to work or
school
8. Wanted my body back to
myself
9. Wanted/needed someone
else to feed the baby
10. Too many household
duties
PREFERENCE ITEMS
11. Did not like breastfeeding
12. Did not want to be tied
down
13. Embarrassment
14. Husband/partner did not
want me to breastfeed
15. Felt it was the right time to
stop
99. DON’T KNOW

[DO NOT READ. CHECK ALL
THAT APPLY]
HEALTH ITEMS
1. Baby had difficulty
nursing
2. Not producing enough
breast milk
3. Baby not gaining
enough weight
4. Nipples sore, cracked or
bleeding
5. Mother or baby became
sick
TIME/DUTY ITEMS
6. Other children to take care
of
7. Went back to work or
school
8. Wanted my body back to
myself
9. Wanted/needed someone
else to feed the baby
10. Too many household
duties
PREFERENCE ITEMS
11. Did not like breastfeeding
12. Did not want to be tied
down
13. Embarrassment
14. Husband/partner did not
want me to breastfeed
15. Felt it was the right time to
stop
99. DON’T KNOW

Page E(B) - 21

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

VERSION B: INFANTS & CHILDREN 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.

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 ______________________________

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

VERSION B: INFANTS & CHILDREN 2-20-09

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
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______________________________
Page E(B) - 23

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

VERSION B: INFANTS & CHILDREN 2-20-09

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: P2g
49. Is your child …[READ]
 Hispanic or Latino?
 Not Hispanic or Latino?
 REFUSED
SKIP IF RECORDED IN PART 1: P2h
50. How would you characterize your child 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
51. What is the highest level of education your child has 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

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

VERSION B: INFANTS & CHILDREN 2-20-09

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(B) - 25

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

VERSION B: INFANTS & CHILDREN 2-20-09

PART 3: TELEPHONE SCREENER FOR IN-HOME AUDIT (Version B)
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 your child’s 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]?
 YES [SKIP TO SD]
 NO, NOT FREE AT THAT TIME [SKIP TO SC]
 NO, REFUSAL [CONTINUE]
SB.

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.

SC.

When would be a good time for you?
 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]

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

VERSION B: INFANTS & CHILDREN 2-20-09

SD.

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:
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? 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(B)- 27

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

VERSION B: INFANTS & CHILDREN 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 for the child—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.
A.
B.
C.
D.

_____________________________
_____________________________
_____________________________
ETC.

Page E(B)- 28

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

VERSION B: INFANTS & CHILDREN 2-20-09

AFTER ALL PERSONS ARE LISTED, ASK FOLLOWING QUESTIONS FOR EACH PERSON:
4. What is their relationship to [SAY You OR
6. Parent/ Guardian
19. Brother-in-law/ sister-inNAME OF SAMPLED PARTICIPANT IF
7. Step-parent
law
DIFFERENT]?
12. Foster parent
20. Other relative
13. Brother/Sister
17. Other non-relative
14. Grandparent
15. Uncle/aunt
16. Cousin
17. Nephew/niece
18. Parent-in-law
5. Is this individual male or female?
 1-Male
 2-Female
6. How old is this person? [IF LESS THAN ONE YEAR, RECORD ―0‖]
_____ 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
 Share like family
expenses and food separately?
 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
ECONOMIC UNIT
PEOPLE IN
 Q8=1 and Q6 ≥15
PRIMARY
ECONOMIC UNIT
10. COMPUTER WILL COMPARE THE NUMBER OF PEOPLE IN PRIMARY ECONOMIC UNIT (Q10) WITH
# OF HOUSEHOLD MEMBERS IN WIC RECORDS (P5-TOTAL IN PRIMARY ECONOMIC UNIT).
IF Q10=P5, SKIP TO Q11
IF Q10P5, SAY: The WIC records show that 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 Q2-10 AS
APPROPRIATE]
FROM PRIMARY ECONOMIC UNIT LIST, COMPUTER WILL GENERATE A LIST OF ―POTENTIAL
WAGE EARNERS‖ – DEFINED AS ALL THE ADULTS AND ALL CHILDREN > 15 YEARS

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

VERSION B: INFANTS & CHILDREN 2-20-09

ADJUNCTIVE OR AUTOMATIC ELIGIBILITY
11. {SKIP TO Q13 IF P3c=NO (i.e., no adjunctive eligibility)]. The WIC records show that your child
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 – WRITE DOWN :
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 ISSUANCE [TYPE IN]______________________
(MM/DD/YYYY)
99 NO DATE [PROBE: Do you have anything
that shows the dates for your participation in the
program?]
c) DATE OF DOCUMENT/CARD OR
[TYPE IN]______________________
ELIGIBILITY EXPIRATION (MM/DD/YYYY)
99 NO DATE [PROBE: Do you have anything that
shows 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 Q14]
 Award letter [SKIP TO Q14]
 Active program voucher [SKIP TO Q14]
 Food Stamp EBT card [SKIP TO Q14]
 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. [THEN
SKIP TO Q14]
 R-7 TANF [NOTE: R- # FORMS ARE MACRO’S INFO RELEASE FORMS]
 R-1 FOOD STAMPS
 R-1 MEDICAID, CHILDREN’S MEDICAID OR CHIP
Page E(B)- 30

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

VERSION B: INFANTS & CHILDREN 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]
[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

$_______

 Tips and bonuses
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: _____

 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

 2007 IRS tax return
 W-2 form
 Other: _____
 None

Page E(B)- 31

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

VERSION B: INFANTS & CHILDREN 2-20-09

$_______

 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

 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
$_______

 Social Security
YES
NO
$_______

stub

 Award statement
 Statement from






insurance company
Other: _____
None
Copy of check
Support agreement
Divorce/separation
decree
Court order
Other: _____
None: GIVE FORM R-6




 Copy of check
 Support agreement
 Divorce/separation

 Per week
 Per 2 weeks
 2 Times a month
decree
 Month
 Court order
 Quarter
 Year
 Other: _____
 Other: _____
 None: GIVE FORM R-6
 Per week
 Per 2 weeks
 2 Times a month
 Month
 Quarter
 Year
 Other: _____

 SSA Award letter
 Statement of benefits
 2007 IRS tax return (line



14a on 1040A)
Other: _____
None

Page E(B)- 32

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

VERSION B: INFANTS & CHILDREN 2-20-09

 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

$_______

 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: _____

$_______

 Per week
 Per 2 weeks
 2 Times a month
 Month
 Quarter
 Year
 Other: _____

 2007 IRS tax return
 Benefits statement
 Copy of check, check

 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

 Other cash income
YES
NO




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

stub

 Other: _____
 None: GIVE FORM R-1

Page E(B)- 33

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

VERSION B: INFANTS & CHILDREN 2-20-09

 Energy assistance
YES
NO
$_______

 Net rental income
YES
NO
$_______

 Income from trusts
YES
NO
$_______

 Commissions
YES
NO
$_______

 Income from estates
YES
NO
$_______

 Net royalties
YES
NO
$_______

 Per week
 Notice of benefits
 Per 2 weeks
 Other: _____
 2 Times a month  None: GIVE FORM R-1
 Month
 Quarter
 Year
 Other: _____
 Per week
 Per 2 weeks
 2 Times a month
 Month
 Quarter
 Year
 Other: _____