Appendix A2: WIC Participant Follow-up Survey
WIC Peer Counseling Study
FOLLOW-UP SURVEY
OMB Clearance Number: 0584-0548 Expiration Date: mm/dd/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 informati on collection is estimated to average 20 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.
Hello, my name is [INTERVIEWER].
Thank you for taking time today to help us. I’m from Abt SRB, and on behalf of United States Department of Agriculture, Food and Nutrition Service we are talking to new mothers about how they are feeding their babies. We also are interested in their experiences receiving services from WIC. [IF BASELINE SURVEY COMPLETED: You may recall completing the first phone survey for this study several months ago. This is the second and final survey for the study.] [IF BASELINE SURVEY NOT COMPLETED: Someone from your WIC agency should have given you information about this study, stating that we would be contacting you to participate in a survey.]
The survey will take about 20 minutes. Your answers could help us learn how to make WIC better for mothers and their babies. Everything you tell me will be kept confidential, to the extent provided by law. We’d like to thank you by giving you a $20 Postal Money Order when we are finished.
Your participation in this survey is voluntary. Your WIC benefits will not be affected if you choose not to participate. If you take part, you may refuse to answer any question. If you take part, your answers won’t change any benefits you receive from WIC. If now is a good time for you and you are willing to participate, I’d like to begin my questions. First, do you have any questions? Are you willing to participate in this survey?
Section A: Infant Information and Feeding Practices
[INTERVIEWER: YOU MUST READ CONSENT TO THE RESPONDENT AND OBTAIN VERBAL CONSENT BEFORE BEGINNING.]
A1. What is your baby’s date of birth?
Infant date of birth: ____ / ____ / ________ [GO TO A2.]
(mm dd yyyy)
REFUSED [GO TO A1a]
DON'T KNOW [GO TO A1a]
A1a. Was your baby born on or after [DUE DATE]?
YES
NO
REFUSED
DON'T KNOW
A2. How much did your baby weigh at birth?
Infant birth weight: _________ pounds _________ ounces
REFUSED
DON'T KNOW
A3. What is your baby’s first name? ________________________________________________
REFUSED
DON'T KNOW
[Let BABY’S NAME = Response on A3. IF A3 =REF or IF A3 = DK, let BABY’S NAME = “Your baby”]
A4. Did you give [BABY’s NAME] breastmilk at any point after delivery?
YES [GO TO A5]
NO [GO TO A4a]
REFUSED [GO TO A4a]
DON'T KNOW [GO TO A4a]
A4a. Did you attempt to breastfeed [BABY’S NAME] at any point after delivery, even if only one time?
YES [GO TO A5]
NO [GO TO B1]
REFUSED [GO TO B1]
DON'T KNOW [GO TO B1]
A5. Are you still giving [BABY’S NAME] breastmilk?
YES [GO TO A6]
NO
REFUSED
DON'T KNOW
[IF A5 = 1 (YES), let variable STILLBF =1; else let variable STILLBF = 0]
A5a. About how many weeks or months did you give your baby breastmilk?
______ Weeks
______ Months
REFUSED
DON'T KNOW
A5b. What are the reasons that you decided to stop giving [BABY’S NAME] breastmilk? [DO NOT READ LIST. MARK RESPONSE(S) GIVEN, THEN PROMPT:] Were there any other reasons that you decided to stop giving your baby breastmilk? [DO NOT READ LIST. MARK RESPONSE(S) GIVEN, THEN PROMPT:] Any other reasons?
BABY WAS PREMATURE
BABY WAS SICK OR I WAS SICK
DIFFICULTY WITH LATCHING, POSITIONING BABY ON BREAST
BREAST OR NIPPLE PAIN, DISCOMFORT, DRYNESS, CRACKING OR INFECTION
BREASTS TOO FULL/SWOLLEN
BABY NOT GETTING ENOUGH MILK
BREASTFEEDING TAKES TOO LONG
BREASTFEEDING WILL CHANGE BREAST APPEARANCE
BREASTFEEDING CAUSES PROBLEMS WITH SEX LIFE
CONCERN ABOUT BREAST MILK LEAKING ONTO CLOTHING
BOTTLE-FEEDING LETS THE BABY’S FATHER/OTHER CAREGIVER BOND WITH BABY
I HAD TO GO BACK TO WORK/SCHOOL
UNCOMFORTABLE BREASTFEEDING IN PUBLIC
PRESSURE FROM FAMILY OR FRIENDS TO STOP BREASTFEEDING
I SMOKE AND A WOMAN WHO SMOKES SHOULD NOT BREASTFEED HER BABY
OTHER, SPECIFY
REFUSED
DON’T KNOW
A6. Which of the following best describes the kind of milk you fed your baby in the last 24 hours? [READ LIST; MARK ONE ONLY.]
Breastmilk only [GO TO B1]
Mostly breastmilk with some formula [GO TO A6b]
Breastmilk and formula about equally [GO TO A6b]
Mostly formula with some breastmilk [GO TO A6b]
Formula only [GO TO A6a]
REFUSED
DON'T KNOW
[IF A6 =1 let variable BFONLY = 1. Else BFONLY = 0]
A6a. Earlier you indicated that you were still breastfeeding your baby. Is this correct?
YES
NO [GO TO A7] [let variable STILLBF = 0]
REFUSED
DON’T KNOW
A6b. Thinking back over the last week, how frequently did you feed your baby breastmilk?
Usually 2 times a day or more often
Usually once a day
Less than once a day
REFUSED
DON'T KNOW
A7. Yesterday, about how many ounces of formula did your baby drink in total? By yesterday, I mean from the time your baby woke up yesterday morning to the time [he/she] woke this morning.
[ENTER NUMBER OF OUNCES] ____________ Ounces [GO TO A8]
REFUSED
DON’T KNOW
PROMPT: if you can’t tell me the number of ounces, can you tell me the number of bottles?
YES
NO [GO TO A8]
REFUSED [GO TO A8]
DON’T KNOW [GO TO A8]
A7a. How many bottles?
[ENTER NUMBER OF BOTTLES] _______ Bottles
A7b. How many ounces are in a bottle?
[ENTER NUMBER OF OUNCES] _______ Ounces
REFUSED
DON'T KNOW
A8. Yesterday, did you feed your baby anything else besides formula or breastmilk? By yesterday, I mean from the time your baby woke up yesterday morning to the time [he/she] woke this morning.
YES
NO [GO TO B1]
REFUSED
DON’T KNOW
A8a. Please tell me what else you fed your baby yesterday and approximately how much. Did you feed [BABY’S NAME]…
|
YES |
NO |
IF YES: How much? |
REF |
DK |
(i) Baby cereal |
|
|
__________ Tbsp/Oz. |
|
|
(ii) Cow’s milk or any other milk |
|
|
__________ Ounces |
|
|
(iii) Plain water |
|
|
__________ Ounces |
|
|
(iv) Juice/sugar water |
|
|
__________ Ounces |
|
|
(v) Table/solid/adult food |
|
|
__________ Tbsp/Oz. |
|
|
(vi) Other (SPECIFY): ________________________ |
|
|
__________ Tbsp/Oz. |
|
|
[IF ANYTHING OTHER THAN PLAIN WATER WAS FED, ASK A8b, ELSE GO TO A8c]
A8b. How old was your baby the first time you fed [him/her] any of these things other than plain water? [IF NEEDED: I am referring to baby cereal, cow’s milk or any other milk, juice or sugar water, and table/solid/adult food.]
__________ Weeks
REFUSED
DON’T KNOW
[IF PLAIN WATER WAS FED (A8a(iii)=YES), ASK A8c, ELSE GO TO B1]
A8c. How old was your baby the first time you fed [him/her] plain water?
__________ Weeks
REFUSED
DON’T KNOW
Section B: WIC Program Experiences During Pregnancy
INTRO: In this section of the interview, I am going to ask you about your experiences with the WIC program during your pregnancy, when you were in the hospital having your baby, and after you got home from the hospital.
B1. How many months pregnant with [BABY’S NAME] were you when you started getting WIC?
__________ Months
REFUSED
DON’T KNOW
B2. When you were pregnant with [BABY’S NAME], did you take a class from WIC that talked about breastfeeding?
YES
NO
REFUSED
DON’T KNOW
B3. While you were pregnant with [BABY’S NAME], did you talk about breastfeeding with a Breastfeeding Peer Counselor from WIC? Breastfeeding Peer Counselors are women who used to get WIC and who breastfed their own babies. WIC hires and trains them to help other women learn about breastfeeding. Did you talk with a Breastfeeding Peer Counselor while you were pregnant with [BABY’S NAME]?
YES
NO [GO TO B9]
REFUSED
DON’T KNOW
B4. While you were pregnant with [BABY'S NAME], how many times did you speak with a Breastfeeding Peer Counselor from WIC about breastfeeding? [READ LIST. MARK ONE ONLY.]
Once
Two or three times
Four or more times
REFUSED
DON'T KNOW
B5. While you were pregnant with [BABY'S NAME], did you ever meet in-person with a Breastfeeding Peer Counselor from WIC to discuss breastfeeding?
YES [GO TO B6]
NO [GO TO B7]
REFUSED [GO TO B7]
DON’T KNOW [GO TO B7]
B6. Where did you meet in-person with this Breastfeeding Peer Counselor while you were pregnant with [BABY'S NAME]? [DO NOT READ LIST. MARK RESPONSE(S) THEN PROMPT:] Did you meet in any other places with a WIC Breastfeeding Peer Counselor while you were pregnant?
AT WIC AGENCY OR CLINIC
IN THE HOSPITAL
IN MY HOME
IN A RELATIVE’S HOME, A FRIEND’S HOME, OR A NEIGHBOR’S HOME
IN THE WIC PERSON’S HOME
IN A PUBLIC PLACE SUCH AS A RESTAURANT, STORE, COMMUNITY CENTER
OTHER, SPECIFY
REFUSED
DON’T KNOW
B7. While you were pregnant with [BABY’S NAME], how did you speak with a Breastfeeding Peer Counselor from WIC about breastfeeding? Did you speak … [READ LIST. MARK ALL THAT APPLY.]
On the telephone
Using text-messages or email
Using a video telephone service such as Skype on a computer
OTHER, SPECIFY:
REFUSED
DON'T KNOW
B8. Have you ever received free text messages on your cellphone about things to do to keep you and your baby healthy?
YES [GO TO B8a]
NO [GO TO C1]
REFUSED
DON'T KNOW
B8a. About when did you start receiving text messages about things to do to keep you and your baby healthy? [READ LIST. MARK ONE.]
When you were between one and three months pregnant with [BABY’S NAME]
When you were between 4-6 months pregnant with [BABY’S NAME]
When you were between 7 to 9 months pregnant with [BABY’S NAME]
During the first week after you delivered [BABY’S NAME]
About 2 to 4 weeks after you delivered [BABY’S NAME]
A month or more after you delivered [BABY’S NAME]
REFUSED
DON'T KNOW
B9b. About when did you most recently receive a text message about things to do to keep you and your baby healthy? [READ LIST. MARK ONE.]
Today or yesterday
A few days ago
About one week ago
About two to three weeks ago
About one to three months ago but after you gave birth to [BABY’S NAME]
Before you gave birth to [BABY’S NAME]
REFUSED
DON'T KNOW
Section C: Breastfeeding and WIC Program Experiences at Delivery
INTRO: In this next section, I’m going to ask about your experiences with the WIC program when you were in the hospital having your baby.
C1. While you were in the hospital for delivery of [BABY’S NAME], did [BABY’S NAME] stay with you in your room or did [BABY’S NAME] stay in the hospital’s nursery?
In my room
In the nursery
OTHER, SPECIFY:
REFUSED
DON'T KNOW
C2. While you were in the hospital for delivery of [BABY’S NAME], did anyone besides a family member or friend help you with breastfeeding by showing you how or talking to you about breastfeeding?
YES
NO
REFUSED
DON’T KNOW
C3. While you were in the hospital for delivery of [BABY’S NAME], did you talk to a Breastfeeding Peer Counselor from WIC about breastfeeding?
YES [GO TO C3a]
NO [GO TO C4]
REFUSED [GO TO C4]
DON’T KNOW [GO TO C4]
C3a. While you were in the hospital for delivery of [BABY’S NAME], how did you talk to this Breastfeeding Peer Counselor : Did you talk… [READ LIST. MARK ALL RESPONSE(S).]
On the phone
In-person
Using text messages or email
OTHER, SPECIFY:
REFUSED
DON’T KNOW
C4. Did you have any questions or problems when you first tried to breastfeed [BABY’S NAME]?
YES
NO [GO TO C3a]
REFUSED
DON’T KNOW
C4a. What questions or problems did you have? [DO NOT READ LIST. CHECK ALL THAT APPLY, THEN PROMPT:] Any other questions or problems?
MY BABY HAD TROUBLE SUCKING/LATCHING ON
BREASTMILK ALONE DID NOT SATISFY MY BABY
MY BABY WAS NOT GAINING ENOUGH WEIGHT
I DIDN’T HAVE ENOUGH MILK/MY BABY WAS NOT GETTING ENOUGH TO EAT
BREASTFEEDING WAS TOO PAINFUL OR UNCOMFORTABLE
OTHER, SPECIFY
REFUSED
DON’T KNOW
C4b. Who did you talk to for help? [DO NOT READ LIST. CHECK ALL THAT APPLY, THEN PROMPT:] Anyone else?
I WANTED TO TALK TO SOMEONE, BUT NEVER DID/DIDN’T KNOW WHO TO ASK
A FRIEND
A RELATIVE
SOMEONE FROM WIC/BREASTFEEDING PEER COUNSELOR FROM WIC
SOMEONE AT MY DOCTOR’S OFFICE
SOMEONE AT THE HOSPITAL
SOMEONE ON A HELPLINE
OTHER, SPECIFY
REFUSED
DON'T KNOW
C5. When you left the hospital after the delivery of [BABY’S NAME], were you given any formula by someone who worked at the hospital?
YES
NO
REFUSED
DON’T KNOW
C6. About how long were you in the hospital after [BABY’S NAME] was born? [REPEAT AND CONFIRM ANSWER PROVIDED]
DAYS
WEEKS
MONTHS
REFUSED [GO TO C7]
DON’T KNOW [GO TO C6a]
C6a. If you don’t remember exactly, which of the following seems about right: After [BABY’S NAME] was born, were you in the hospital for: [READ LIST. CHECK ONE.]
Less than 24 hours
About 1 day
About 2-3 days
About 4-5 days
About 1 week
About 2 to 3 weeks
About 1 month or longer
C7. Did [BABY’S NAME] come home with you when you left the hospital?
YES [GO TO D1]
NO [GO TO C7a]
REFUSED [GO TO D1]
DON’T KNOW [GO TO C7a]
C7a. About how long was [BABY’S NAME] in the hospital after delivery? [REPEAT AND CONFIRM ANSWER PROVIDED]
DAYS
WEEKS
MONTHS
REFUSED [GO TO D1]
DON’T KNOW [GO TO C7b]
C7b. If you don’t remember exactly how long, which of the following seems about right: [BABY’S NAME] was in the hospital for [READ LIST. CHECK ONE.]
Less than 24 hours
About 1 day
About 2-3 days
About 4-5 days
About 1 week
About 2 to 3 weeks
About 1 month or longer
Section D: WIC Program Experiences after delivery
INTRO: In this next section, I’m going to ask about your experiences with the WIC program after you got home from the hospital with [BABY’S NAME].
D1. After [BABY'S NAME] was born, did you ever have a telephone conversation about breastfeeding with a Breastfeeding Peer Counselor from WIC? I’m not referring to any telephone calls about scheduling an appointment or about certifying your infant. I’m asking about a telephone conversation with a Breastfeeding Peer Counselor from WIC where you talked about breastfeeding.
Yes [GO TO D2]
No [GO TO D3]
REFUSED [GO TO D3]
DON'T KNOW [GO TO D3]
D2. About how long after [BABY'S NAME] was born did you first have a telephone conversation about breastfeeding with a Breastfeeding Peer Counselor from WIC?
During the first week to 10 days after giving birth
About two weeks after giving birth
About two or three weeks after giving birth
About one month after giving birth
More than one month after giving birth
REFUSED
DON'T KNOW
D3. After [BABY’S NAME] was born, did you ever meet in person with a Breastfeeding Peer Counselor from WIC?
YES [GO TO D4]
NO [GO TO D5]
REFUSED [GO TO D5]
DON’T KNOW [GO TO D5]
D4. About how long after [BABY’S NAME] was born did you first meet in-person with a Breastfeeding Peer Counselor from WIC?
During the first week to 10 days after giving birth [GO TO E1]
About two weeks after giving birth [GO TO E1]
About three weeks after giving birth [GO TO E1]
About one month after giving birth [GO TO E1]
More than one month after giving birth [GO TO E1]
REFUSED [GO TO E1]
DON'T KNOW [GO TO E1]
D5. Did a Breastfeeding Peer Counselor from WIC ever try to contact you after [BABY’S NAME] was born?
YES [GO TO D5a]
NO [GO TO F1]
REFUSED [GO TO F1]
DON’T KNOW [GO TO F1]
D5a. Were there any particular reasons you could not speak or did not want to speak with the Breastfeeding Peer Counselor from WIC who tried to contact you? DO NOT READ LIST. CHECK ALL THAT APPLY. PROMPT: Any other reasons?
I WAS SICK
MY BABY WAS SICK
MY PHONE/DOORBELL WASN’T WORKING
IT WASN’T A GOOD TIME
I WAS SLEEPING/TOO TIRED TO TALK
I WASN’T HAVING ANY PROBLEMS FEEDING THE BABY
I HAD ALREADY DECIDED I DID NOT WANT TO BREASTFEED
I WAS WORKING/IN SCHOOL WHEN THEY TRIED TO REACH ME
I TRIED TO CALL THEM BACK UNSUCCESSFULLY
OTHER, SPECIFY:
REFUSED
DON’T KNOW
GO TO F1.
Section E: In-Person Meeting With Peer Counselor
E1. Where did you first meet in-person with the Breastfeeding Peer Counselor from WIC after [BABY'S NAME] was born?
AT MY WIC AGENCY OR WIC CLINIC
IN THE HOSPITAL
IN MY HOME
IN A RELATIVE’S HOME, A FRIEND’S HOME, OR A NEIGHBOR’S HOME
AT A ANOTHER LOCATION: SPECIFY
REFUSED
DON’T KNOW
E2. How long did that first in-person meeting last? [READ LIST. CHECK ONE REPONSE.]
Less than 30 minutes
Between 30 minutes and an hour
About an hour
About an hour and a half
About two hours
More than two hours
REFUSED
DON'T KNOW
E3. Did you breastfeed [BABY’S NAME] during this in-person meeting with the Breastfeeding Peer Counselor from WIC?
YES
NO
REFUSED
DON’T KNOW
E4. What breastfeeding topics did you discuss with the Breastfeeding Peer Counselor during this first in-person meeting after [BABY’S NAME] was born? [DO NOT READ LIST. MARK RESPONSES(S), THEN PROMPT:] Any other topics?
[BABY’S NAME]’S ABILITY TO SUCK OR LATCH-ON TO GET MILK FROM BREASTFEEDING
[BABY’S NAME]’S HUNGER OR FEEDING SCHEDULE
[BABY’S NAME]’S HEALTH OR WEIGHT GAIN
MY MILK SUPPLY
TECHNIQUES TO MAKE BREASTFEEDING EASIER
BREASTFEEDING PAIN OR DISCOMFORT
HOW TO BREASTFEED IF I WANT TO GO BACK TO WORK/SCHOOL
USING A BREAST PUMP, OR STORING MILK THAT I HAVE PUMPED
REASONS I SHOULD TRY NOT TO USE FORMULA
BELIEFS AND ATTITUDES OF [BABY’S NAME]’S FATHER, MY FAMILY MEMBERS, OR MY FRIENDS ABOUT BREASTFEEDING
MY ATTITUDES OR BELIEFS ABOUT BREASTFEEDING
EMBARRASSMENT, ANXIETY, OR OTHER EMOTIONS THAT I FELT ABOUT BREASTFEEDING
OTHER, SPECIFY:
REFUSED
DON’T KNOW
E5. Was your Breastfeeding Peer Counselor able to answer your questions about breastfeeding?
YES
NO
REFUSED
DON’T KNOW
E6. How comfortable did you feel talking about breastfeeding with the Breastfeeding Peer Counselor from WIC during this in-person meeting? Very comfortable, somewhat comfortable, somewhat uncomfortable, or very uncomfortable?
Very comfortable
Somewhat comfortable
Somewhat uncomfortable
Very uncomfortable
REFUSED
DON'T KNOW
Section F. Final Questions about Infant Feeding
[IF BFONLY=1 SKIP TO F2. ELSE GO TO F1]
F1. Why did you start feeding your baby formula? [DO NOT READ LIST. MARK RESPONSE(S) GIVEN, THEN PROMPT:] Were there any other reasons that you decided to start feeding your baby formula? [DO NOT READ LIST. MARK RESPONSE(S) GIVEN, THEN PROMPT:] Any other reasons?
BABY WAS PREMATURE
BABY WAS SICK OR I WAS SICK
DIFFICULTY WITH LATCHING, POSITIONING BABY ON BREAST
BREAST OR NIPPLE PAIN, DISCOMFORT, DRYNESS, CRACKING OR INFECTION
BREASTS TOO FULL/SWOLLEN
BABY NOT GETTING ENOUGH MILK
BREASTFEEDING TAKES TOO LONG
BREASTFEEDING WILL CHANGE BREAST APPEARANCE
BREASTFEEDING CAUSES PROBLEMS WITH SEX LIFE
CONCERN ABOUT BREAST MILK LEAKING ONTO CLOTHING
BOTTLE-FEEDING LETS THE BABY’S FATHER/OTHER CAREGIVER BOND WITH BABY
I HAD TO GO BACK TO WORK/SCHOOL
UNCOMFORTABLE BREASTFEEDING IN PUBLIC
PRESSURE FROM FAMILY OR FRIENDS TO STOP BREASTFEEDING
I SMOKE AND A WOMAN WHO SMOKES SHOULD NOT BREASTFEED HER BABY
OTHER, SPECIFY
REFUSED
DON’T KNOW
Section G: Employment
Now I’m going to ask you some general questions about work, child care, and about people in your household.
G1. Are you
currently employed?
G2. What is the average number of hours you work per week?
____________ Hours per week
VARIABLE
REFUSED
DON'T KNOW
G3. In your opinion, how supportive is your workplace of breastfeeding?
Not at all supportive
Not too supportive
Somewhat supportive
Very supportive
REFUSED
DON'T KNOW
G4a. Does your worksite have a breastfeeding room available to you?
YES
NO
REFUSED
DON’T KNOW
G4b. Does your worksite have other places where women can breastfeed? What kinds of places? [READ LIST. CHECK ALL THAT APPLY.]
Ladies/women’s restroom
A lunchroom
A staff lounge, meeting room, or unoccupied office
My own office
No places where women can breastfeed
OTHER, SPECIFY
REFUSED
DON’T KNOW
[IF STILLBF=1, THEN ASK G5, ELSE GO TO H1]
G5. Which of the following circumstances describe your situation during the past (4) weeks? Tell me all that apply: [READ LIST. CHECK ALL THAT APPLY.]
I breastfeed my baby during my work day
I pump milk during my work day and dump it
I pump milk during my work day and save it for my baby to drink later
I neither pump nor breastfeed during my work day
REFUSED
DON'T KNOW
Section H: Child Care
H1. Did someone other than you care for your baby for more than 3 hours at one time in the last week?
YES
NO [GO TO K1]
REFUSED
DON’T KNOW
H2. Does the person who took care of your baby do so on a regular basis? This could be for work or non-work related reasons (for example, you had classes or other activities).
YES
NO [GO TO K1]
REFUSED
DON’T KNOW
H3. How many days in the last week was your baby cared for by someone else?
____________ Days per week [IF ZERO, GO TO K1]
REFUSED
DON'T KNOW
H4. On an average day in the last week, how many hours was [he/she] cared for by someone else?
____________ Hours per day
REFUSED
DON'T KNOW
Section K: Demographic Characteristics
K1. How many people currently live in your household? That is, how many adults and children who stay with you all or most of the time are part of your household? Please include yourself in the total.
TOTAL HOUSEHOLD MEMBERS ______________
REFUSED
DON'T KNOW
K2. How many of the persons who live in your household are under the age of
18? Please include all of the persons under age 18, including [BABY’S NAME], who stay with you all or most of the time.
TOTAL HOUSEHOLD MEMBERS UNDER AGE 18 ______________
REFUSED
DON'T KNOW
K3. What is your current marital status? [READ LIST. CHECK ONE ONLY.]
Never married
Married/living with partner
Divorced
Legally separated
Widowed
REFUSED
DON'T KNOW
K4. What was the highest grade/level of school you completed? [DO NOT READ LIST. CHECK ONE ONLY.]
DID NOT GRADUATE HIGH SCHOOL
HIGH SCHOOL GRADUATE OR GED
SOME COLLEGE OR 2-YEAR DEGREE
4-YEAR COLLEGE GRADUATE
MORE THAN 4-YEAR COLLEGE DEGREE
REFUSED
DON'T KNOW
[PREFILL K5 TO K8 WITH DATA FROM BASELINE SURVEY IF AVAILABLE]
K5. What is your ethnic background? Are you…
Hispanic or Latino
Not Hispanic or Latino
REFUSED
DON'T KNOW
K6. Please choose one or more categories to describe your race.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
OTHER, SPECIFY
REFUSED
DON'T KNOW
K7. Where were you born?
One of the 50 US states or the District of Columbia
One of the US Territories (PROBE: Puerto Rico, Guam, American Samoa, US Virgin Islands, Mariana Islands, or Solomon Islands)
Some other country (SPECIFY)
REFUSED
DON'T KNOW
K8. When were you born?
____ / ____ / ________
(mm dd yyyy)
REFUSED
DON'T KNOW
K9. Please indicate your total annual household income. [READ LIST. CHECK ONE ONLY.]
Less than $10,000
Between $10,001 – $15,000
Between $15,001 – $20,000
Between $20,001 – $25,000
Between $25,001 – $30,000
Between $30,001 – $35,000
Between $35,001 – $40,000
More than $40,000
REFUSED
DON'T KNOW
K10. Do you currently receive any of the following? [READ LIST. CHECK ALL THAT APPLY.]
SNAP Benefits (formerly Food Stamps)
TANF or cash assistance
Medicaid
Welfare
REFUSED
DON'T KNOW
GO TO CLOSING
CLOSING
Thank you.
As I mentioned earlier, we’d like to thank you by giving you a $20 Postal Money Order in appreciation of your participation. So that we can mail it to you, please give me the correct spelling of your name and your address.
Respondent name__________________________________
Street Address __________________________________
Apartment or building number, etc. ____________________
City ___________________________
State __________________________ Zip ____________________________
As part of a routine check on the quality of the work that I am doing, my supervisor also may contact you by phone. I'd like to verify that the number I've reached you at now is the correct number for us to call. The number I have is
NUMBER DIALED:______________________________________
Is this correct?
YES
NO [IF NO, ENTER IN CORRECT NUMBER BELOW]
CORRECT NUMBER ____________________________________
Thank you. We will mail your money order to the address you provided.
Thanks again for your time and your participation.
Abt Associates Inc. WIC Participant Follow-up Survey
| File Type | application/msword |
| File Title | Abt Single-Sided Body Template |
| Author | NicholsonJ |
| Last Modified By | Carter Epstein |
| File Modified | 2011-05-13 |
| File Created | 2011-05-06 |