State, Local and/or Tribal Agencies

OMB Control#: 0584-0548

Expiration Date: xx/xx/20xx

Appendix C6: Peer Counseling Refusal/Withdrawal Form

Peer Counseling Refusal/ Withdrawal Form

OMB Clearance Number: 0584-0548 Expiration Date: xx/xx/20xx

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0548. The time required to complete this information collection is estimated to average 3 minutes per response. If you have any comments concerning the accuracy of time estimates or suggestions for improving this form, please contact: U. S. Department of Agriculture, Food and Nutrition Service, Office of Research & Analysis, Room 1014, Alexandria, VA 22302.

Instructions to Peer Counselor:

• If a WIC participant withdraws from the Loving Support Peer Counseling program and she had enrolled in the WIC Peer Counseling Study, please complete PAGE 1 of this form.

• If you attempted, but were unable, to meet in-person with a WIC participant enrolled in the study, please complete PAGE 2 of this form.

Do not write the WIC Participant’s name anywhere on this form.

Withdrawal from Breastfeeding Peer Counseling

Participant’s Study ID			__ __	__	__ __ __
Today’s Date			dd/ month /yyyy
Due date of infant (or birthdate)			dd/ month /yyyy
Name of person completing this form:			Do not write WIC participant’s name here
Reason(s) given for withdrawing from breastfeeding peer counseling: Check all that apply
		Too busy
		Transportation difficulty
		Perinatal death/pregnancy terminated
		Mother is sick, not feeling well
		Does not want to breastfeed her baby
		Unknown/no reason given/no contact made
		Other reason(s), describe:

Please give this form to [Name of local WIC agency Study Contact].

Peer Counseling Meeting Refusal

Participant’s Study ID

__ __

__

__ __ __

Today’s Date

dd/ month /yyyy

Birth date of infant

dd/ month /yyyy

Peer Counselor Name

Do not write WIC participant’s name here

Outcome of attempt to meet in-person



No show or no answer



Said she does not want an in-person meeting



Requested a new meeting time

Next in-person meeting:



Requested phone call

dd/month/yyyy

Where did you attempt to meet with this WIC participant? Mark one answer



At her home



At a WIC clinic



Other location, specify:

Reason(s) given for declining the in-person meeting: Check all that apply



Not a good time right now



Transportation difficulty



Baby is sick or in the hospital



Mother is sick, not feeling well



Baby sleeping



Forgot about appointment



Does not want to breastfeed



Does not want breastfeeding assistance – FILL OUT PEER COUNSELING CLOSURE FORM



Unknown/no reason given/no contact made



Other reason(s), describe:

Follow-up planned:



None



Will attempt to reschedule in-person meeting



Will attempt telephone peer counseling contact



Call to confirm withdrawal from peer counseling program



Other, describe:

Please give this form to [Name of local WIC agency Study Contact].