WIC Participant

OMB Approval No. 0584-XXXX

Approval Expires: XX/XX/20XX

Appendix G.1

Postnatal Enrollment Package Letter - ENGLISH

[Recipient Name]

[Street Address]

[City, ST ZIP Code]

Dear [Recipient Name]:

Thank you so much for talking to us [at site name/by phone] on [enrollment date] and joining the WIC Feeding My Baby study! You are now in a select group of people who will help inform America about the choices WIC families make in feeding their children.

This Study Welcome package includes the following:

• A Payoneer Prepaid MasterCard with $50 to thank you for joining the Feeding My Baby study. Please hold on to the card until your baby is 2 years old.  The blue sheet provides instructions on how to use the card.  The money you receive for participating in the study will be added to this card.   You can receive:

  • $20 for each phone interview, up to [$220 IF CORE/$80 FOR SUPPLEMENTAL]

  • An additional $10 for each phone interview if you use your own cell phone minutes, up to [$110 IF CORE/$40 IF SUPPLEMENTAL]

  • An additional $20 if you are selected for a second short interview (lasting about 10 minutes) about what your child ate and drank on a selected day.

• [For those recruited by phone] A consent form that answers any questions you might have about your participation in this important study.

• HIPAA form [If core, postnatal group] that authorizes us to get records about your baby’s birth from the hospital where you gave birth, and the information about your baby’s height and weight from your baby’s pediatrician. Please sign and return the form to us in the enclosed postage-paid return envelope.

• A calendar on the yellow sheet that shows the four-week period when we will call you to complete each followup interview. It also has a toll-free number, 1-888-888-8888, which you can use to call us during each interview period to complete an interview. You may find it helpful to place the calendar on your refrigerator.

• [If sending a cell phone] A cell phone that we would like you to use for your next followup interview. Instructions for the phone are included.

• A set of measuring guides including measuring cups and spoons, a household teaspoon and tablespoon, and a ruler to help you with the next interviews that ask about the type and amount of food the child eats on a given day.

If you have any other questions, please contact your study liaison, [Sally Smith]. She can be reached by e-mail at ______________, and you can also call or text her at _________________.

We are so happy you made the decision to join the Feeding My Baby study and we look forward to talking to you over the next few years.

Enclosures

1. Debit Card with $50

2. Payoneer Card Instructions

3. Cardholder Frequently Asked Questions

4. Terms and Conditions

5. Follow up Interview Calendar

6. HIPAA form

7. Cell Phone with Instruction Sheet (For participants who need a cell phone and whose next interview is within X months)

8. Consent Form (for participants enrolled by telephone)

9. Return Envelope

10. Measuring guides

Payoneer Card Instructions

We are pleased to present your new Payoneer Prepaid Mastercard® card!

• You will receive your Feeding My Baby study incentives on this card.

• Use your card for purchases at any merchant where Mastercard® is accepted.

• If you are asked, select “Credit” at the register and sign for your purchase if required.

• If you are asked for a PIN at the register, ask the cashier to process the transaction as ‘Credit’

• For gas purchases, present your card to the cashier – the card cannot be used to pay-at-the-pump.

• This card cannot be used to access cash at an ATM.

• You may be able to get cash from a bank teller. Check with your bank for its policies and the applicable fees.

• Split Tender Transactions.  When making a purchase for an amount greater than your available balance, you can ask the merchant to charge an amount equal to your available balance and then pay the remainder using another form of payment.

• A monthly maintenance fee of $3 will be applied if you do not use the card. Please see the attached information on card fees for more details.

• If you have any questions regarding use of the card, including balance inquiry or a lost/stolen card, please contact [toll-free number]

Cardholder Frequently Asked Questions

1) What is the participant compensation card?

The participant compensation card is a prepaid MasterCard® card which will be used to deposit your study related payments. The card is not a credit card.

2) Do I have to activate my card?

No. You will be able to use your card as soon as funds are deposited onto the card. Contact the Westat Payoneer Help Desk at XX-XXX-XXXX for more information on when your card will be loaded.

3) How do I check my card balance or transaction history?

Your study coordinator will inform you of your card balance when you receive your card. Make sure to keep your receipts to track your remaining card balance and transaction history. For your convenience, the compensation card register is provided below to assist you in tracking your card balance and transaction history. If you need to contact cardholder customer support, you may do so at: http://www.payoneer.com/contactUs.aspx. To send an email, use the multilingual email form at: http://www.payoneer.com/EmailForm.aspx. You can also check your card balance and transaction history anytime by calling 1-888-500-7754 (from within the United States) or +1-646-386-2428 (from outside the United States).

4) Where can I use my card to make purchases?

Your card can be used to make purchases anywhere MasterCard is accepted; at the point-of-sale, online or by phone. Common purchases include food, gasoline and transportation. When making a purchase for an amount greater than your available balance, instruct the merchant to charge an amount equal to or less than your available balance and then pay the remainder using another form of payment.

5) How do I use my card to make purchases?

At the point-of-sale, simply present your card to the cashier and sign the receipt. If you’re asked to choose between CREDIT and DEBIT, you must select CREDIT for your transaction to be processed successful. Your card does not have a PIN associated with it. When making a purchase over the phone or internet, you must enter the billing address associated with your card. The billing address is located on the card carrier that came with your card. When making a purchase for an amount greater than your available balance, instruct the merchant to charge an amount equal to your available balance and then pay the remainder using another form of payment.

6) Can I use my card to withdrawal cash?

Yes. You may withdrawal cash by presenting your card to a bank teller inside any bank that displays the MasterCard logo. Advise the bank teller: “I would like to withdrawal cash from my prepaid MasterCard card” and request an amount that is less than or equal to your available card balance. The bank teller may ask you to show valid identification and sign a receipt to complete the transaction. Note: There is no PIN associated with your card so you cannot use it an ATM to withdraw cash or get cash back when making a purchase.

7) Can I use my card to pay-at-the-pump at gas stations?

No. Your card must be presented to the attendant inside the gas station to pay for your transaction. Instruct the attendant to charge a specific amount that is less than or equal to your card balance. Any additional amount due can be paid with a separate form of payment.

8) Can I use my card at restaurants?

Yes. Please keep in mind that restaurants will attempt to authorize your card for an amount over your bill to cover for gratuity. As a result, make sure to instruct your waiter or waitress to only authorize an amount equal to or less than your card balance. Any additional amount due can be paid with a separate form of payment.

9) Who do I contact if I lose my card or have further questions about my card?

Contact the study location where you received your card.

10) When does my card expire?

The expiration date is located on the front of your card. Your card expires on the last day of the month listed. If you still have funds on your card and your card has expired, contact the study location where you received your card to request a new card and balance transfer.

11) Are there any fees associated with the card?

Please refer to the Fee Schedule below. To avoid incurring a maintenance fee, simply make one transaction with your card every calendar month after your initial deposit or spend the entire balance on your card. The maintenance fee will never cause your card account to go negative and will not apply if there is Qualifying Activity. Qualifying Activity includes payments loaded onto your card and purchase transactions.

Cut along the dotted line and keep with your card

F ee Schedule
Description	Fee
Purchase transaction	Free
ATM transaction *	N/A
Bank Teller Cash Withdrawal	$1.00
Card Replacement	Free
Live Agent Customer Service	Free
Automated Phone Customer Service	Free
Email Customer Service	Free
Live Chat Customer Service	Free
Monthly Maintenance Fee **	$3.00
Foreign Transaction Processing	Up to 5%
* Your card cannot be used to withdrawal cash at an ATM
** After the initial deposit onto your card, a monthly maintenance fee may be assessed to your card account if no Qualifying Activity has been initiated with your card account in the preceding month.

The Payoneer prepaid MasterCard is issued by Choice Bank Limited, pursuant to a license by MasterCard International Incorporated. MasterCard is a registered trademark of MasterCard International Incorporated.

Follow up Interview Calendar for Core Participants

(Baby born on March 15, 2013 and enrolled at age <1month)

Thank you for your participation in the WIC Feeding My Baby study.

We will be contacting you for follow up interviews during the times listed below.

You will receive $20 for each interview.

You can also call us at [toll free number] during the interview times to complete the interview.

[DATES TO BE DETERMINED AFTER OMB APPROVAL]

First Follow up Interview
Second Follow up Interview
Third Follow up interview
Fourth Follow up Interview
Fifth Follow up Interview
Sixth Follow up Interview
Seventh Follow up Interview
Eighth Follow up Interview
Ninth Follow up Interview
Final Follow up Interview

Please let us know of any changes in your address or phone number by contacting your Study Liaison [STUDY LIASIONNAME] at [STUDY LIASION PHONE NUMBER AND EMAIL ADDRESS] or[toll-free number]

Follow up Interview Calendar for Supplemental Participants

(Baby born on March 15, 2013 and enrolled at age <1month)

Thank you for your participation in the WIC Feeding My Baby study.

We will be contacting you for follow up interviews during the times listed below.

You will receive $20 for each interview.

You can also call us at [toll free number] during the interview times to complete the interview.

[DATES TO BE DETERMINED AFTER OMB APPROVAL]

First Follow up Interview
Second Follow up Interview
Third Follow up Interview
Final Follow up Interview

Please let us know of any changes in your address or phone number by contacting your Study Liaison [STUDY LIASIONNAME] at [STUDY LIASION PHONE NUMBER AND EMAIL ADDRESS] or[toll-free number]

Permission to Get Information from Medical Records

WIC Feeding My Baby Study

Food and Nutrition Service, U.S. Department of Agriculture

If you sign this document, you are giving permission to (1) the hospital or medical facility where you gave birth to your child, and (2) your child’s doctor, to release health information that identifies you to Westat for the WIC Feeding My Baby Study. The health information that we will use for the Feeding My Baby Study includes both your medical records and your child’s medical records from the hospital stay when you gave birth to your child; and, your child’s weight, length, and health status information from your child’s doctor up until your child is two years old. Westat will use this health information, along with information you give during your interviews and information from your WIC records, to learn more about the health and feeding choices of WIC families.

Both the hospital or medical facility where you gave birth, and your child’s doctor, are required by law to protect your health information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) prevents them from releasing your health information without your permission. Once your information is released to Westat it is no longer protected by HIPAA, but the same privacy protections Westat takes with your other information will also apply to your medical records. Your name and your child’s name will not be used in any research reports, and Westat will not share personal information about you with WIC or with anyone else who is not on the study staff.

The hospital, medical facility, or your child’s doctor may not refuse to treat you because of your decision to sign or not sign this authorization. You can change your mind and take back this authorization at any time by contacting the Feeding My Baby study by phone at XXX-XXX-XXXX or in writing at [Address]. The Feeding My Baby study would not seek any more records about you or your child, but would still use any records that had already been released.

By signing this document, you are authorizing the hospital or medical facility where you gave birth, and your child’s doctor, to release your health information to Westat for this research. The health records are for care provided only during the study period of November 1, 2012, to April 1, 2016.

I am voluntarily giving permission for my medical records and my child’s medical records, as described above, to be released to Westat for the Feeding My Baby Study.

Patient’s Name (Mother):

Please Print Your Full Name

Date of Birth: ____ / ____ / ____

Month Day Year

Patient’s Name (Child):

Please Print Your Child’s Full Name

Date of Birth: ____ / ____ / ____

Month Day Year

Patient’s Signature (Mother):

Date Signed:

If the mother is a minor, her parent’s or guardian’s signature is also needed:

Parent or Guardian Signature (for Mother):

Signer’s Relationship to Mother:

Date signed:

A parent or guardian’s signature is needed for the child’s records:

Parent or Guardian Signature (for Child):

Signer’s Relationship to Child:

Date signed:

CELLPHONE INSTRUCTIONS

A cellphone, charger, and a booklet with detailed instructions are included in the enclosed package.

The phone number is __[CELLPHONE NUMBER]_______________________

Network: ___[CARRIER NAME]_______________

TO TURN THE PHONE ON OR OFF: [INSTRUCTION SPECIFIC TO THE SELECTED DEVICE]

TO PLACE A CALL: [INSTRUCTION SPECIFIC TO THE SELECTED DEVICE]

TO SET UP YOUR VOICEMAIL:

[INSTRUCTIONS SPECIFIC TO THE SELECTED DEVICE AND CARRIER]

TO USE VOICEMAIL:

[INSTRUCTIONS SPECIFIC TO THE SELECTED DEVICE AND CARRIER].

****There is NO text message or data plan on this phone.****

Your cellphone has XXX minutes of talk time. A day or two before your next follow up interview, we will provide you with [NUMBER OF MINUTES PER THE SELECTED PLAN] minutes so you can complete the interview and receive $20.

Please make sure to charge the phone and keep it with you on the days you have appointments for your follow up interviews, and check your voicemail frequently for any study messages.

Please contact your Study Liaison if the cellphone is lost, stolen, or damaged. For problems using the cellphone please contact [TOLL FREE NUMBER]

We look forward to speaking with you soon.

PICTURES OF THE MEASURING GUIDES

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 5 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.