State, Local and/or Tribal Agencies

WIC Breastfeeding Peer Counseling Study Phase 2

Appx C6 RefusalWithdraw

State, Local and/or Tribal Agencies

OMB: 0584-0548

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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].




File Typeapplication/msword
File TitleDECLINE form
AuthorEpsteinC
Last Modified ByCarter Epstein
File Modified2011-05-13
File Created2011-05-13

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