State and Local WIC-Screener, Staff, Personnel

OMB Approval No. 0584-XXXX

Approval Expires: XX/XX/20XX

WIC Site Name: [Preprinted]

WIC Site ID: [Preprinted]

	Date _________ Appendix D.1 Eligible Participant Referral Form - ENGLISH

Complete one form for each new WIC Enrollee for the Feeding My Baby Study if:

Prenatal enrollees must:

• Be at least 16 years old

• Be enrolling in WIC for the first time for this pregnancy

• Speak either English or Spanish

Postnatal enrollees must be the parent/guardian of the enrolled baby and must:

• Be at least 16 years old

• Be enrolling a baby less than 3 months of age whose mother was not enrolled in WIC during pregnancy

• Speak either English or Spanish

To be Completed by WIC Staff:

MOTHER’S WIC ID: _______________________________________

BABY’S WIC ID: ___________________________________________

FAMILY WIC ID: __________________________________________

1. Name/ Nombre: _______________ ______________ _______________

FIRST/ PRIMERO MIDDLE/SEGUNDO LAST/APELLIDO

2. Pregnant/Está embarazada: □ YES/SÍ □ NO

3. Preferred Language/ Idioma de preferencia: □ ENGLISH □ ESPAÑOL

4. Age/Edad: □ 16 – 17 □ 18 – 20 □ 21+

If under age 18 please provide/Si tiene menos de 18 años de edad, favor de proveer la siguiente información:

1. Parent or Guardian Name/ Nombre del padre, madre o tutor :

_______________________________

2. Parent or Guardian Phone Number/Número de teléfono del padre, madre o tutor: ____________________________

5. Phone Number/Número de teléfono: _________________________

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Give the yellow copy to the eligible participant. WIC staff keeps white copy.

Thank you for your participation in the Feeding My Baby Study.

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 1 minute 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.