WIC Participant

OMB Approval No. 0584-XXXX

Approval Expires: XX/XX/20XX

APPENDIX E.1

WIC ITFPS-2 Participant Interview

Screening/Enrollment - English

Screening Items

Check to see if participant is in the system as a potentially eligible WIC enrollee listed by the WIC clinic. Confirm WIC ID and name.

CM2. {If have WIC ID on file: We have your WIC ID as {FILL}, is that correct? / If don’t have WIC ID on file: Do you know what your current WIC ID is?}

WIC ID is the same (fill below) 01

New WIC ID (specify below) 02

Don’t know WIC ID 98

Refused WIC ID 99

WIC ID___________________________________

CM1. Can you please tell me what your full legal name is now?

Record full name:

First________________________________________________

Middle______________________________________________

Last ________________________________________________

I’d like to start by asking you some background questions to see if you are eligible for the Feeding My Baby Study.

If postnatal, start with SE6. If prenatal, skip to SE1.

Relation to child

Enrollment

If postnatal:

SE6. Thinking of the newborn baby you enrolled in WIC (If in person at site: today/If by phone: in the past week or so) are you the baby’s mother or the person who is mainly responsible for caring for the child? [Source: New Development]

Yes, mother 01

Yes, primary caregiver 02

No, neither 03

If SE6 = 01, go to SE2.

If SE6 = 02 or 03, go to SE7.

SE7. (Ask if not mother) What is your relationship to the baby? [Source: New Development]

Father 01

Grandmother 02

Other relative (specify) 03

Foster parent 04

Ask SE8 only if SE6 = 03.

SE8. (Ask if neither mother nor primary caregiver) While we appreciate you talking with us, we can only include people in our study who are either the child’s mother or who have main responsibility for caring for the child. Can you please tell us how to get in touch with the child’s mother or primary caregiver? [Source: New Development]

Record contact info.

If SE6 = 03, respondent is not eligible to enroll. Discontinue and contact mother or primary caregiver if provided in SE8.

First Time in WIC for pregnancy/child

Screening/Enrollment

If prenatal:

SE1. Before you enrolled in WIC (If in person at site: today/If by phone: in the past week or so), have you received benefits from WIC for this pregnancy? [Source: New Development]

Yes 01

No 02

Don't know 98

Refused 99

If SE1 = 01, respondent is not eligible. Confirm response.

If postnatal:

SE2. Before you enrolled in WIC (If in person at site: today/If by phone: in the past week or so), have you received benefits from WIC for your newborn baby? [Source: New Development]

Yes 01

No 02

Don't know 98

Refused 99

SE3. Did you get food from WIC for yourself when you were pregnant with your newborn baby? [Source: New Development]

Yes 01

No 02

Don't know 98

Refused 99

If SE2 or SE3 = 01, respondent is not eligible. Confirm response.

Infant DOB

Enrollment if postnatal or if recruited prenatal, 1 mo

Ask SD5 and SD6 only if postnatal. If prenatal, skip to SD4

SD5. {EN: Thinking of the newborn baby you just enrolled in WIC}What month was {EN: this child; 1 mo: CHILD} born? [Source: WIC IFPS-1]

Month [January – December]

SD6. {EN: Thinking of the newborn baby you just enrolled in WIC / 1 mo: And } what day of the month was {CHILD} born?

Day [1-31]

{Year – autofill for last occurrence of the month}

Don't know 98

Refused 99

Single or Multiple Birth

Enrollment or if recruited prenatal 1 mo

Ask only if postnatal. If prenatal, skip to SD4.

SD7. Did you have twins, or more than one baby? [Source: FDA IFPS-2]

Yes 01

No 02

If yes, need to sample one child for study. Go to SD44. If no, go to SD2.

SD44. How many babies did you have? Please include only live births.

Number of live births [number]

Program selects random child. Interviewer says: I’ll be asking you about the {NUMBER} child you just gave birth to. Just so I remember which child I am asking about, what is that child’s first name?

First Name________________________________________________

Due date

Screening/Enrollment, if prenatal

Ask only if prenatal. If postnatal, skip to SD2.

SD4. When is your baby due? [Source: FDA IFPS-2]. (If mother doesn’t know due date, probe: Do you know the month your baby is due? Do you know if your baby is due at the beginning, middle or end of that month?)

NOTE: If mother indicates only estimate of day, code beginning as 1, middle as 15, end as last day of month

Month [January – Dec.]

Day [1-31]

{Year – autofill for next occurrence of the month}

NOTE FOR CALCULATION OF TRIMESTER:

Week 1 – Week 12: first trimester

Week 13 – 28: second trimester

Week 29 – 40/birth: third trimester

Source: DHHS Office on Women’s Health, http://womenshealth.gov/pregnancy/you-are-pregnant/stages-of-pregnancy.cfm

Maternal/Caregiver Ethnicity

Enrollment

SD2. Are you Latino or Hispanic? [Source: CHIRP Study; modified]

Hispanic or Latino 01

Not Hispanic or Latino 02

Don’t know 98

Refused 99

Maternal/Caregiver Race

Enrollment

SD3. What is your race? (open-ended, choose all that apply) [Source: OMB Standard Categories]

American Indian or Alaska Native 01

Asian 02

Black or African American 03

Native Hawaiian or Other Pacific Islander 04

White 05

Other (specify____________________________________) 06

Don't know 98

Refused 99

Pre-pregnancy weight/obesity

Screening

Ask MH1 and MH2 only if the respondent is the mother. Otherwise, skip to MH29.

MH1. How tall are you? [Source: New Development]

Feet [2-6]

Inches [0-11]

MH2. In the month before you got pregnant about how much did you weigh, without shoes? [Source: PHFE WIC 2010 Postpartum Questionnaire; modified]

Pounds [number]

Ask MH29 only if the respondent is not the child’s mother.

MH29. Thinking about this child’s birth mother, in the month before she got pregnant would you say that she was normal weight, overweight, or very overweight?

Normal 01

Overweight 02

Very overweight 03

Don’t know 98

Refused 99

Household size

Enrollment, 7, 13, 24

SD18. How many people live in your household? By household I mean people who live together and share living expenses. Please include yourself in this count, and (If PN enrollment: please add 1 to the total for your pregnancy, too/If postnatal enrollment or 7, 13, or 24 months: If you are pregnant right now please add 1 to the total for your pregnancy. [Source: FITS 2002, modified]

Number of people in household [number]

Household income

Enrollment, 7, 13, 24

SD19. During [PREVIOUS MONTH], what was your household income before taxes? Please include any income in the past month from you, your family members who live with you, and any other people who live with you and share living expenses with you [Source: WIC IFPS-1, modified]

Income [amount]

(OR if respondent cannot provide specific amount): I’ll read some ranges, and you can stop me when I get to the one that is your best estimate of your household income before taxes for [PREVIOUS MONTH]

$500 or less 01

$501-$1000 02

$1001-$1500 03

$1501-$2000 04

$2001-$2500 05

$2501-$3000 06

$3001-$3500 07

$3501-$4000 08

$4001-$4500 09

$4501-$5000 10

$5001+ 11

Don’t know 98

Refused 99

Enrollment Items

Administer after consent (and assent if needed) if the respondent is eligible for the study and wants to enroll

{PN: To get you into the study, I need to ask you a few more questions about yourself/Postnatal: To get you into the study I need to ask you a few more questions about yourself and your baby}

If one child was selected from multiple birth: Remember that for this study I’m only asking you about {CHILD FIRST NAME}, not about your other babies.

Child Sex

Enrollment or if recruited prenatal, 1 mo

SD8. Is your baby a boy or a girl? [Source: WIC IFPS-1]

Boy 01

Girl 02

Child Name

Enrollment or if recruited prenatal, 1 mo

SD9. What is your baby's full name? Please spell that for me. [Source: New Development]

Record full name:

First________________________________________________

Middle______________________________________________

Last ________________________________________________

a. Is there a nickname you use for {CHILD} that you would like me to use while talking with you?

(If yes) Nickname _____________________________________

Child Ethnicity

Enrollment or if recruited prenatal, 1 mo

SD10. Is {CHILD} Latino or Hispanic?

Hispanic or Latino 01

Not Hispanic or Latino 02

Don’t know 98

Refused 99

Child Race

Enrollment or if recruited prenatal, 1 mo

SD11. What is {CHILD’S} race? (Open ended - Interviewer select all that apply) [Source: OMB Standard Categories]

American Indian or Alaska Native 01

Asian 02

Black or African American 03

Native Hawaiian or Other Pacific Islander 04

White 05

Other (specify____________________________________) 06

Don't know 98

Refused 99

Maternal birth date

Enrollment

SD1. What is your date of birth? [Source: FITS 2008; modified]

a. First tell me the year

Year [number]

b. What month were you born?

Month [January – December]

c. And what day of the month?

Day [1-31]

Contact Information

Enrollment

Thank you for taking the time to speak with me today. Because we’ll be calling you again for your next interview (EN: in a couple of weeks / all other times: when your child is {AGE – next interview}), I’d like to be sure we have all the right ways to contact you.

CM3. {If interviewer initiated call} I reached you today at {FILL #}. Will that still be the best number to call you at for your next interview?

Yes (if yes, go to b) 01

No (if no, go to a) 02

a. {If interviewer did not initiate call} What is the best number to call you at for your next interview?

Number (specify ---/---/----)

NO PHONE (go to CM4) 97

Is that number home, work, cell, or something else?

Home 01

Work 02

Cell 03

Other (specify__________________) 04

b. Is there another number we could try in case we have trouble reaching you?

Number (specify ---/---/----)

Is that number home, work, cell, or something else?

Home 01

Work 02

Cell 03

Other (specify__________________) 04

We’d like to keep in touch with you even if we can’t get you by phone or your phone number changes, so I’m going to ask you about a few additional ways we might be able to contact you.

CM4. If have email on file: We have your email address as {FILL}, is that correct?/If no email: Do you have an email address we could use to contact you if necessary?

Email is the same (fill below) 01

New Email (specify below) 02

Don’t know Email 98

Refused Email 99

Email___________________________________

CM5. If mailing address on file: We have your current mailing address as {FILL}. Is that correct? If no mailing address on file: Can I get a mailing address we could use to contact you if necessary?

Address is the same (fill below) 01

New address (specify below) 02

Don’t know/don’t have address 98

Refused address 99

a. Can you please tell me what your current mailing address is?

Street/Apt#________________________________________

City______________________________________________

State_____________________________________________

ZIP______________________________________________

b. (If CM3a is 97 – no phone): Earlier you indicated that you do not have a phone. Since we need to speak with you by phone we will mail you a study phone. You will receive the phone before your next interview. The package will contain instructions on how to use the phone. Should we mail the phone to the mailing address you just provided?

Address is the same (fill below) 01

New address (specify below) 02

Don’t know/don’t have address 98

Refused address 99

Can you please provide the address where the phone should be mailed?

Street/Apt#________________________________________

City______________________________________________

State_____________________________________________

ZIP______________________________________________

CM6. [Social Media – will develop question when procedure is finalized]

CM7. (If contacts on file: Earlier you provided the names and contact information for two people who would always know how to find you. Can I read that information back to you and check that it’s still up to date?/If no contacts on file: Just in case we can’t get in touch with you using the information you just gave me, I’d like to ask you for the names and contact information for two people who would always know how to find you.

Person #1 (If contacts on file, read fill info and correct as needed)

Name

Who is this person to you?

Phone

Address

Email

Person #2 (If contacts on file, read fill info and correct as needed)

Name

Who is this person to you?

Phone

Address

Email

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB number.  The valid OMB control number for this information collection is 0584-XXXX.  The time required to complete this information collection is estimated to average 17 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.