OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

WIC Participant

IC 203577 under ICR 201208-0584-002 · OMB 0584-0580.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
App E 1_Eng Screening_Enrollment Participant Interview (revised).docx Other-App.E.1_Eng.Screening_Enrollme
App E 2_Span Screening Enrollment Participant Interview (revised).docx Other-App.E.2_Span.Screening_Enrollm
App.F.1_Eng.Prenatal Enrollment Package.Letter.docx Other-App.F.1_Eng.Prenatal Enrollmen
App.F.2_Span Prenatal Enrollment Package.Letter.docx Other-App.F.2_Span.Prenatal Enrollme
App.G 1_Eng Postnatal Enrollment Package Letter.V2.docx Other-App.G 1_Eng Postnatal Enrollme
App.G 2_Span Postnatal Enrollment Package Letter.V2.docx Other-App.G 2_Span Postnatal Enrollm
App.I.1_Eng.Prental Participant Interview.docx Other-App.I.1_Eng.Prental Participan
App.I.2_Span.Prenatal Participant Interview.docx Other-App.I.2_Span.Prenatal Particip
App.J.1_Eng.1 Month Participant Interview (revised).docx Other-App.J.1_Eng.1 Month Participan
App.J.2_Span.1 Month Participant Interview (revised).docx Other-App.J.2_Span.1 Month Participa
App.K.1_Eng.3 Month Participant Interview.docx Other-App.K.1_Eng.3 Month Participan
App.K.2_Span.3 Month Participant Interview.docx Other-App.K.2_Span.3 Month Participa
App.L.1_Eng.5 Month Participant Interview.docx Other-App.L.1_Eng.5 Month Participan
App.L.2_Span.5 Month Participant Interview.docx Other-App.L.2_Span.5 Month Participa
App.M.1_Eng.7 Month Participant Interview.docx Other-App.M.1_Eng.7 Month Participan
App.M.2_Span.7 Month Participant Interview.docx Other-App.M.2_Span.7 Month Participa
App.N.1_Eng.9 Month Participant Interview.docx Other-App.N.1_Eng.9 Month Participan
App.N.2_Span.9 Month Participant Interview.docx Other-App.N.2_Span.9 Month Participa
App.O.1_Eng.11 Month Participant Interview.docx Other-App.O.1_Eng.11 Month Participa
App.O.2_Span.11 Month Participant Interview.docx Other-App.O.2_Span.11 Month Particip
App.P.1_Eng.13 Month Participant Interview.docx Other-App.P.1_Eng.13 Month Participa
App.P.2_Span.13 Month Participant Interview.docx Other-App.P.2_Span.13 Month Particip
App.Q.1_Eng.15 Month Participant Interview.docx Other-App.Q.1_Eng.15 Month Participa
App.Q.2_Span.15 Month Participant Interview.docx Other-App.Q.2_Span.15 Month Particip
App.R.1_Eng.18 Month Participant Interview.docx Other-App.R.1_Eng.18 Month Participa
App.R.2_Span.18 Month Participant Interview.docx Other-App.R.2_Span.18 Month Particip
App.S.1_Eng.24 Month Participant Interview.docx Other-App.S.1_Eng.24 Month Participa
App.S.2_Span.24 Month Participant Interview.docx Other-App.S.2_Span.24 Month Particip
App.T.1_Eng.Baseline module.Participant.Interview.docx Other-App.T.1_Eng.Baseline module.Pa
App.T.2_Span.Baseline module.Participant.Interview.docx Other-App.T.2_Span.Baseline module.P
App.U.1_Eng.New Caregiver module.Participant.Interview.docx Other-App.U.1_Eng.New Caregiver modu
App.U.2_Span.New Caregiver module.Participant.Interview.docx Other-App.U.2_Span.New Caregiver mod
App.V.1 Eng Automated Multiple Pass Method 24HR.Module.Screenshots (revised).pdf Other-App.V.1 Eng Automated Multiple
App.DD.1_Eng.HomeHealthcareAgency.LengthWeight.Form.docx Other-App.DD.1_Eng.HomeHealthcareAge
App.DD.2_Span.HomeHealthcareAgency.LengthWeight.Form.V2.docx Other-App.DD.2_Span.HomeHealthcareAg
App.EE.1_Eng.Home Health Visit Script.LengthWeight.docx Other-App.EE.1_Eng.Home Health Visit
App.EE.2_Span.Home Health Visit Script.LengthWeight.docx Other-App.EE.2_Span.Home Health Visi
App V 2_Span Automated Multiple Pass Method 24HR Module Screenshots.pdf Other-App V 2_Span Automated Multipl
App.A.1_Eng.WIC Poster-v2.pdf
App.A.1_Eng.WIC Poster		IC Document
App.A.2_Span.WIC Poster-V2.pdf
App.A.2_Span.WIC Poster		IC Document
App.B.1_Eng.Participant Flyer.docx
App.B.1_Eng.Participant Flyer		IC Document
App.B.2_Span.Participant Flyer.docx
App.B.2_Span.Participant Flyer		IC Document
App.H 1_Eng Post Birth HIPAA Letter.V2.docx
App.H 1_Eng Post Birth HIPAA Letter		IC Document
App.H 2_Span Post Birth HIPAA Letter.V2.docx
App.H 2_Span Post Birth HIPAA Letter		IC Document
App.Y.1_Eng_Core Participant Informed Consent Amended Privacy (23May13).docx
App.Y.1_Eng_Core Participant Informed Consent		IC Document
App.Y.2_Span_Core Participant Informed Consent Amended Privacy (23May13).docx
App.Y.2_Span_Core Participant Informed Consent		IC Document
App.Z.1_Eng_Supplemental Participant Consent Amended Privacy (23May13)docx.docx
App.Z.1_Eng_Supplemental Participant Consent		IC Document
App.Z.2_Span_Supplemental Participant Consent Amended Privacy(23May13).docx
App.Z.2_Span_Supplemental Participant Consent		IC Document
App.NN.1_Eng.Participant Reminder Scripts.docx
App.NN.1_Eng.Participant Reminder Scripts		IC Document
App.NN.2_Span.Participant Reminder Scripts.docx
App.NN.2_Span.Participant Reminder Scripts		IC Document
App.OO.1_Eng.Thankyou Letter.docx
App.OO.1_Eng.Thankyou Letter		IC Document
App.OO.2_Span.Thankyou Letter.docx
App.OO.2_Span.Thankyou Letter		IC Document
App.TT.Confidentiality & Nondisclosure Agreement.docx
App.TT.Confidentiality & Nondisclosure Agreement		IC Document
App.W.1_Eng 13 Month FoodModelBooklet.Letter.docx
App.W.1_Eng 13 Month FoodModelBooklet.Letter		IC Document
App.W.2_Span 13 Month FoodModelBooklet.Letter.docx
App.W.2_Span 13 Month FoodModelBooklet.Letter		IC Document
App.X.1_Eng Note sheet for AMPM.docx
App.X.1_Eng Note sheet for AMPM.docx		IC Document
App.X.2_Span Note sheet for AMPM.docx
App.X.2_Span Note sheet for AMPM		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-App.E.1_Eng.Screening_Enrollment.Participant.Interview. Yes Yes Fillable Fileable
Other-App.E.2_Span.Screening_Enrollment.Participant.Interview Yes Yes Fillable Fileable
Other-App.F.1_Eng.Prenatal Enrollment Package.Letter No   Paper Only
Other-App.F.2_Span.Prenatal Enrollment Package.Letter No   Paper Only
Other-App.G 1_Eng Postnatal Enrollment Package Letter No   Paper Only
Other-App.G 2_Span Postnatal Enrollment Package Letter No   Paper Only
Other-App.I.1_Eng.Prental Participant Interview Yes Yes Fillable Fileable
Other-App.I.2_Span.Prenatal Participant Interview Yes Yes Fillable Fileable
Other-App.J.1_Eng.1 Month Participant Interview Yes Yes Fillable Fileable
Other-App.J.2_Span.1 Month Participant Interview Yes Yes Fillable Fileable
Other-App.K.1_Eng.3 Month Participant Interview Yes Yes Fillable Fileable
Other-App.K.2_Span.3 Month Participant Interview Yes Yes Fillable Fileable
Other-App.L.1_Eng.5 Month Participant Interview Yes Yes Fillable Fileable
Other-App.L.2_Span.5 Month Participant Interview Yes Yes Fillable Fileable
Other-App.M.1_Eng.7 Month Participant Interview Yes Yes Fillable Fileable
Other-App.M.2_Span.7 Month Participant Interview Yes Yes Fillable Fileable
Other-App.N.1_Eng.9 Month Participant Interview Yes Yes Fillable Fileable
Other-App.N.2_Span.9 Month Participant Interview Yes Yes Fillable Fileable
Other-App.O.1_Eng.11 Month Participant Interview Yes Yes Fillable Fileable
Other-App.O.2_Span.11 Month Participant Interview Yes Yes Fillable Fileable
Other-App.P.1_Eng.13 Month Participant Interview Yes Yes Fillable Fileable
Other-App.P.2_Span.13 Month Participant Interview Yes Yes Fillable Fileable
Other-App.Q.1_Eng.15 Month Participant Interview Yes Yes Fillable Fileable
Other-App.Q.2_Span.15 Month Participant Interview Yes Yes Fillable Fileable
Other-App.R.1_Eng.18 Month Participant Interview Yes Yes Fillable Fileable
Other-App.R.2_Span.18 Month Participant Interview Yes Yes Fillable Fileable
Other-App.S.1_Eng.24 Month Participant Interview Yes Yes Fillable Fileable
Other-App.S.2_Span.24 Month Participant Interview Yes Yes Fillable Fileable
Other-App.T.1_Eng.Baseline module.Participant.Interview Yes Yes Fillable Fileable
Other-App.T.2_Span.Baseline module.Participant.Interview Yes Yes Fillable Fileable
Other-App.U.1_Eng.New Caregiver module.Participant.Interview Yes Yes Fillable Fileable
Other-App.U.2_Span.New Caregiver module.Participant.Interview Yes Yes Fillable Fileable
Other-App.V.1 Eng Automated Multiple Pass Method 24HR.Module.Screenshots (revised) Yes Yes Fillable Fileable
Other-App.DD.1_Eng.HomeHealthcareAgency.LengthWeight.Form No   Paper Only
Other-App.DD.2_Span.HomeHealthcareAgency.LengthWeight.Form No   Paper Only
Other-App.EE.1_Eng.Home Health Visit Script.LengthWeight No   Paper Only
Other-App.EE.2_Span.Home Health Visit Script.LengthWeight No   Paper Only
Other-App V 2_Span Automated Multiple Pass Method 24HR Module Screenshots Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 18,667 0 18,667 0 0 0
Annual IC Time Burden (Hours) 4,426 0 4,426 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
App.A.1_Eng.WIC Poster 12/18/2012
App.A.2_Span.WIC Poster 12/18/2012
App.B.1_Eng.Participant Flyer 12/18/2012
App.B.2_Span.Participant Flyer 12/18/2012
App.H 1_Eng Post Birth HIPAA Letter 12/18/2012
App.H 2_Span Post Birth HIPAA Letter 12/18/2012
App.Y.1_Eng_Core Participant Informed Consent 05/23/2013
App.Y.2_Span_Core Participant Informed Consent 05/23/2013
App.Z.1_Eng_Supplemental Participant Consent 05/23/2013
App.Z.2_Span_Supplemental Participant Consent 05/23/2013
App.NN.1_Eng.Participant Reminder Scripts 12/18/2012
App.NN.2_Span.Participant Reminder Scripts 12/18/2012
App.OO.1_Eng.Thankyou Letter 12/18/2012
App.OO.2_Span.Thankyou Letter 12/18/2012
App.TT.Confidentiality & Nondisclosure Agreement 12/18/2012
App.W.1_Eng 13 Month FoodModelBooklet.Letter 12/19/2012
App.W.2_Span 13 Month FoodModelBooklet.Letter 12/19/2012
App.X.1_Eng Note sheet for AMPM.docx 12/19/2012
App.X.2_Span Note sheet for AMPM 12/19/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].