WIC Participant

OMB Approval No. 0584-XXXX

Approval Expires: XX/XX/20XX

APPENDIX O.1

WIC ITFPS-2 Participant Interview

11 Month - ENGLISH

SOCIODEMOGRAPHICS AND BACKGROUND

Respondent still Caregiver?

1, 3, 5, 7, 9, 11, 13, 15, 18, 24

SD12. (1 mo.: Before we go any further/ All other: Before we begin today), I need to ask whether you are still {CHILD's} caregiver. [Source: New Development]

Yes 01

No 02

(If no, go to a)

a. Does {CHILD} still live with you?

Yes 01

No 02

b. (If a is Yes): Can you please tell me who in your household is now {CHILD's} caregiver? Can I speak with that person?

Name of New Caregiver______________________________________________

c. (If a is No): Can you please tell me who is caring for {CHILD} now, and how I could reach that person?

Name of New Caregiver______________________________________________

Phone of New Caregiver______________________________________________

Address of New Caregiver____________________________________________

Relation of New Caregiver to Child_____________________________________

Continuation/discontinuation of WIC participation (timing, reasons, location)

1, 3, 5, 7, 9, 11, 13, 15, 18, 24

I’d like to begin by asking you some questions about WIC.

SD31. Are you currently getting WIC food or checks for yourself or {CHILD}? [Source: FDA IFPS-2; modified]

Yes 01

No 02

(if no for the first time go to SD34, if no previously go to next applicable module)

SD32. The last time we talked with you, you were going to WIC at [fill in location]. Do you still go there, or do you go to a new location? [Source: FDA IFPS-2 modified]

Yes, still that location 01

No, new location 02

SD33. (If SD32 is no) Please tell me where you go now

Record location _______________________________________

Ask SD34 and SD35 only if SD31 is 'no'

SD34. How old was {CHILD} when you stopped going to WIC? [Source: LA WIC Survey; modified]

Age [weeks/months]

SD35. I'm going to read some reasons why you might have stopped going to WIC. Please tell me if each one is a reason you stopped going to WIC: [Source: LA WIC Survey; modified]

You no longer qualify for WIC 01

It was inconvenient for you 02

You no longer need WIC 03

Other reason (record response) 04

CURRENT FEEDING PRACTICES

AMPM Module (Asking child’s food intake in past 24 hours)

24-HR Recall for Food Intake

1, 3, 5, 7, 9, 11, 13, 15, 18, 24

Nutrition intake

Number of breastmilk/formula feedings per day

Type of formula used

Adherence to formula dilution instructions

Use/timing of supplemental formula for breastfeeding mothers

Addition of anything other than human milk/formula to child’s bottle

Specific food item intake

Use of jarred baby foods

Meal and snack pattern

Eating locations (eating on the go)

Use of dietary supplements for infants (direct administration)

Now I’m going to ask you some questions about things you might be doing to feed your baby.

Current feeding choice

1, 3, 5, 7, 9, 11, 13

CF1. Are you currently feeding {CHILD} breastmilk either from your breast or from a bottle, formula, (1-5 months: or both) (7-13 months: both, or neither)? [Source: New Development]

Only breastmilk 01

Only formula 02

Both breastmilk and formula 03

Neither breastmilk nor formula 04

IF CF1 = 02, SKIP TO CF19

IF CF1 = 04, AND CF30 NOT ADMINISTERED AT A PREVIOUS INTERVIEW, GO TO CF30.

IF CF1 = 04, AND CF30 ADMINISTERED AT A PREVIOUS INTERVIEW, GO TO CF34.

Breastfeeding Module (Asked only if mother currently feeding breastmilk, based on CF1)

Questions CF6 – CF18

You said that you are currently feeding {CHILD} breastmilk. I’d like to ask you some questions about that now.

Use of breast pump

1, 3, 5, 7, 9, 11, 13

CF6. Some mothers are able to pump breastmilk and others are not. Are you currently pumping breastmilk?

Interviewer: code yes if mother is pumping at all, even if infrequently.

Yes 01

No 02

Refused 99

If CF6 = NO, skip to CF18.

Time of day of pumping

1, 3, 5, 7, 9, 11, 13

Ask only if currently pumping breastmilk in CF6

CF12. Now I’d like to ask you about the times of day when you usually pump. [Source: New Development]

a. When you pump, how often do you pump in the morning, before noon? Would you say usually, sometimes, or never?

Usually 01

Sometimes 02

Never 03

Don’t know 98

Refused 99

b. When you pump, how often do you pump mid-day, from noon to 5pm? Would you say usually, sometimes, or never?

Usually 01

Sometimes 02

Never 03

Don’t know 98

Refused 99

c. When you pump, how often to you pump in the evening or night time, after 5pm? Would you say usually, sometimes, or never?

Usually 01

Sometimes 02

Never 03

Don’t know 98

Refused 99

Frequency of pumping

1, 3, 5, 7, 9, 11, 13

Ask only if currently pumping breastmilk in CF6

CF11. Thinking about the past two weeks, how many times did you pump milk? (Interviewer allow open-ended, calculate numbers for response if needed, and confirm with respondent)[Source: FDA IFPS-2, modified]

Times pumped [times]

Storage practices for pumped/expressed human milk

1, 3, 5, 7, 9, 11, 13

Ask only if currently pumping breastmilk in CF6

CF16. In the last month, how long was your pumped milk usually stored in the refrigerator? [Source: FDA IFPS-2, modified]

I do not store milk in a refrigerator 01

1 day or less 02

2 to 3 days 03

4 to 5 days 04

6 to 8 days 05

More than 8 days 06

CF17. How long is your frozen milk usually stored? [Source: FDA IFPS-2]

I do not freeze my milk 01

Less than 1 week 02

1 to 4 weeks 03

1 to 3 months 04

4 months or more 05

How is breastmilk feeding schedule determined (time schedule, child seems hungry, mixed)

1, 3, 5, 7, 9, 11, 13

CF18. Do you breastfeed or feed {CHILD} breastmilk from a bottle on a regular schedule, or when [HE/SHE] cries or seems hungry? [Source: IFPS-1, modified]

Schedule 01

Cries or seems hungry 02

Both on a schedule and when baby cries or seems hungry 03

IF CF1 = 01 SKIP TO CF52

Formula Feeding Module (Asked only if mother currently formula feeding)

Questions CF19 – CF27

Who provided formula

1, 3, 5, 7, 9, 11, 13

You said that you are currently feeding {CHILD} formula. I’d like to ask you some questions about that.

CF19. Where do you get the formula that you use to feed {CHILD}? Do you get it from WIC, from somewhere else, or both WIC and somewhere else? [Source: New Development]

WIC 01

Somewhere else 02

Both WIC and somewhere else 03

CF20. (If indicated in CF19 getting formula from WIC) Is the amount of formula that you get from WIC to help feed {CHILD} more than you usually need, less than you usually need, or about right? [Source: PHFE WIC Survey 2010, modified]

More 01

Less 02

About right 03

Don’t know 98

Refused 99

Reasons for formula use

1, 3, 5, 7, 9, 11, 13 (ask for the last time at the interview where mom indicates she has completely stopped breastfeeding)

CF21. There are many reasons for using formula. Please tell me if any of the following are reasons why you feed your baby formula? [Source: FDA IFPS-2, modified]

If not currently breastfeeding at all (CF1) and never tried to breastfeed (HF10, CF29), skip to h.

Ask (a) only in months 1, 3, 5

a. My baby had trouble sucking or latching on to the breast

Yes 01

No 02

b. My baby lost interest in nursing or began to stop nursing by him or herself

Yes 01

No 02

c. Breastmilk alone did not satisfy my baby

Yes 01

No 02

d. I thought that my baby was not gaining enough weight

Yes 01

No 02

e. I didn’t have enough breastmilk

Yes 01

No 02

f. Breastfeeding was too painful

Yes 01

No 02

g. I wanted my baby to have both formula and breastmilk.

Yes 01

No 02

Ask h-n if mother is either exclusively formula feeding or feeding both breastmilk and formula

h. I chose not to breastfeed

Yes 01

No 02

i. My baby was sick and could not breastfeed

Yes 01

No 02

j. I was sick or had to take medicine

Yes 01

No 02

k. Breastfeeding seemed too inconvenient

Yes 01

No 02

l. I could not or did not want to pump

Yes 01

No 02

m. I wanted or needed someone else to feed my baby

Yes 01

No 02

n. For another reason

Yes (specify______________________________________) 01

No 02

New Formula Food Safety Questions

3, 7, 11

People have different routines they follow when preparing formula. Now I’d like to ask you about things you might do when you prepare formula for your baby.

CF54. In the past month, when you prepared infant formula for {CHILD} how often did you mix it with water that you had boiled first? Would you say you did that always, sometimes, never, or did you use ready-to-feed formula instead?

Always 01

Sometimes 02

Never 03

Use ready-to-feed [skip next Q] 04

CF55. Some people mix their infant formula with water, and keep it until they need it to feed their babies. In the past month, how often did you mix infant formula more than 24 hours before you fed it to {CHILD}? Would you say that you always mixed it more than 24 hours before you fed it to {CHILD}, sometimes did that, never did that, or did you use ready-to-feed formula instead?

Always 01

Sometimes 02

Never 03

Use ready-to-feed 04

If not adhering to formula dilution instructions, why? Prescribed by Dr., nutritionist?

1, 3, 5, 7, 9, 11, 13

CF22. In the past month, did you ever mix the formula with extra water to make it last longer? [Source: IFPS-1]

Yes 01

No 02

If CF22 = NO, skip to CF24.

CF23. (If yes to CF22) Who told you to prepare the formula this way? [Source: New Development]

Doctor 01

Someone who works at the WIC office or clinic 02

Another health care provider 03

Friend 04

Family member 05

Other 06

No one told me 07

CF24. In the past month, did you ever mix the formula with less water than directed in order to concentrate it or make it stronger? [Source: IFPS-1, modified]

Yes 01

No 02

Not applicable – use ready-to-feed 03

If CF24 = NO, skip to CF27.

CF25. (If yes to CF24) Who told you to prepare the formula this way? [Source: New Development]

Doctor 01

Someone who works at the WIC office or clinic 02

Another health care provider 03

Friend 04

Family member 05

Other 06

No one told me 07

How is formula feeding schedule determined (set, on demand, mixed)

1, 3, 5, 7, 9, 11, 13

CF27. Do you feed {CHILD} formula on a regular schedule or when [HE/SHE] cries or seems hungry? [Source: IFPS-1]

Schedule 01

Cries or seems hungry 02

Both on a schedule and when baby cries or seems hungry 03

Move to Partial Breastfeeding

Timing of move to partial breastfeeding

(any time 1-13)

Ask of all women who indicated fully BF in CF1. Once answered affirmatively, drop from subsequent interviews.

CF52. Has {CHILD} ever been fed infant formula, even just one time? Do not count while you were in the hospital after {CHILD’s} birth.

Yes 01 (go to CF53)

No 02 (go to CF32)

Don’t know 03

Refused 04

Ask of fully BF women who answered yes to CF52, partially BF women (based on CF1), and fully formula feeding women (based in CF1) who indicated that they ever breastfed in CF29 or HF10. Ask once, first time formula feeding indicated in CF1 or CF52, then drop from subsequent interviews.

CF53. How old was {CHILD} the first time he/she was fed infant formula? Do not count while you were in the hospital after {CHILD’S} birth.

Age [days/weeks/months]

Don’t know 98

Refused 99

Asked of all partially BF women and all fully formula feeding women who ever breastfed based on CF29 or HF10. Ask until an age, don’t know, or refused is given in response, then drop from subsequent interviews.

CF28. How old was {CHILD} when (he/she) was first fed formula every day? [Source: FITS 2002, modified]

Age [days/weeks/months]

Child is not fed formula every day 97

Don’t Know 98

Refused 99

Breastfeeding Cessation Module: (asked once first time mother indicates not currently feeding breastmilk in CF1)

Questions CF30 – CF31

Timing of cessation of breastfeeding

(any time 1-13)

Ask at first interview when mother says she is not feeding breastmilk, if she indicated feeding breastmilk in CF1 on previous interviews or if she answered ‘yes’ to ever breastfed or tried to breastfeed in CF29

CF30. How old was {CHILD} when you completely stopped breastfeeding or feeding [HIM/HER] breastmilk from a bottle? [Source: IFPS-1, modified]

Age [days/weeks/months]

Reasons for cessation of breastfeeding

(any time 1-13)

CF31. There are many reasons mothers stop breastfeeding. Please tell me if any of the following reasons helped you to decide to stop breastfeeding {CHILD}? [Source: FDA IFPS-2, modified]

Do not ask (a) if interview is 5 months or later

a. My baby had trouble sucking or latching on

Yes 01

No 02

b. My baby began to bite

Yes 01

No 02

c. My baby lost interest in nursing or began to stop nursing by him or herself

Yes 01

No 02

d. Breastmilk alone did not satisfy my baby

Yes 01

No 02

e. I thought that my baby was not gaining enough weight

Yes 01

No 02

f. I didn’t have enough milk

Yes 01

No 02

g. Breastfeeding was too painful

Yes 01

No 02

h. I was sick or had to take medicine

Yes 01

No 02

i. Breastfeeding was too inconvenient

Yes 01

No 02

j. I wanted or needed someone else to feed my baby

Yes 01

No 02

k. I did not want to breastfeed in public

Yes 01

No 02

l. Another reason (specify ________________________________)

Yes 01

No 02

Time to cessation of bottle feeding

7, 9, 11, 13, 15, 18, 24 (ask until affirmative, then stop asking)

CF34. Is {CHILD} still drinking anything from a bottle? [Source: New Development]

Yes 01

No 02

CF35. (If CF34 = NO, ask:) How old was {CHILD} when he/she stopped using a bottle? [Source: New Development]

Age [weeks/months/years]

Supplemental Foods Initiation (asked all interviews 1-24 until all endorsed)

Fed other than breastmilk or formula

1, 3, 5, 7, 9, 11, 13, 15, 18, 24

Ask CF32 at every interview until mother answers yes, then drop from later interviews and go straight to CF33.

CF32. Has {CHILD} been given anything to eat or drink besides formula or breastmilk? [Source: WIC IFPS-1, modified]

Yes 01

No 02

Time to introduction of supplemental foods

1, 3, 5, 7, 9, 11, 13, 15, 18, 24

Next I’m going to ask you some questions about when you first started feeding {CHILD} different types of foods.

Ask each food until answer is affirmative, then stop asking that food in subsequent interviews

CF33. For each of the following, please tell me if {CHILD} has been given this food or drink, and if so, how old {CHILD} was when he/she first had that food. [Sources: FITS 2008; IFPS-1; WHO Toolkit 1996]

a. Has [HE/SHE] been given plain bottled or tap water?

Yes 01

No 02

b. (If yes) How old was {CHILD} when [HE/SHE] was first fed plain bottled or tap water?

Age [weeks/months]

Don’t know 98

Refused 99

c. Has [HE/SHE] been given soda or soft drinks?

Yes 01

No 02

d. (If yes) How old was {CHILD} when [HE/SHE] was first fed soda or soft drinks?

Age [weeks/months]

Don’t know 98

Refused 99

e. Has [HE/SHE] been given other sweetened beverages (such as Kool Aid, Hi-C, Fruit Punch, sweetened juice, sweetened or flavored water, Gatorade, or sweet tea)?

Yes 01

No 02

f. (If yes) How old was {CHILD} when [HE/SHE] was first fed other sweetened beverages?

Age [weeks/months]

Don’t know 98

Refused 99

g. Has [HE/SHE] been given 100% fruit juice such as apple juice, orange juice, or other types of 100% juice. Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to?

Yes 01

No 02

h. (If yes) How old was {CHILD} when [HE/SHE] was first fed 100% fruit juice?

Age [weeks/months]

Don’t know 98

Refused 99

i. Has [HE/SHE] been given other drinks and liquids, including teas and broths?

Yes 01

No 02

j. (If yes) How old was {CHILD} when [HE/SHE] was first fed Other drinks and liquids, including teas and broths?

Age [weeks/months]

Don’t know 98

Refused 99

k. Has [HE/SHE] been given Cow’s milk, including whole milk, 2%, 1%, or skim? Please include milk you add to other foods such as cereal.

Yes 01

No 02

l. (If yes) How old was {CHILD} when [HE/SHE] was first fed cow’s milk?

Age [weeks/months]

Don’t know 98

Refused 99

m. Has [HE/SHE] been given dairy products other than cow’s milk including cheese, yogurt, or goat’s milk? Please include any dairy products other than cow’s milk that you add to other foods.

Yes 01

No 02

n. (If yes) How old was {CHILD} when [HE/SHE] was first fed dairy products other than cow’s milk?

Age [weeks/months]

Don’t know 98

Refused 99

o. Has [HE/SHE] been given baby cereal, either with a spoon or by adding it to a bottle of breastmilk or formula?

Yes 01

No 02

p. (If yes) How old was {CHILD} when [HE/SHE] was first fed baby cereal?

Age [weeks/months]

Don’t know 98

Refused 99

q. Has [HE/SHE] been given other cereal besides baby cereal?

Yes 01

No 02

r. (If yes) How old was {CHILD} when [HE/SHE] was first fed other cereal besides baby cereal?

Age [weeks/months]

Don’t know 98

Refused 99

s. Has [HE/SHE] been given eggs?

Yes 01

No 02

t. (If yes) How old was {CHILD} when [HE/SHE] was first fed eggs?

Age [weeks/months]

Don’t know 98

Refused 99

u. Has [HE/SHE] been given fruit, including baby food or regular fruit?

Yes 01

No 02

v. (If yes) How old was {CHILD} when [HE/SHE] was first fed fruit?

Age [weeks/months]

Don’t know 98

Refused 99

w. Has [HE/SHE] been given vegetables, including baby food or regular vegetables?

Yes 01

No 02

x. (If yes) How old was {CHILD} when [HE/SHE] was first fed vegetables?

Age [weeks/months]

Don’t know 98

Refused 99

y. Has [HE/SHE] been given beans, such as black beans, pinto beans, or chick peas?

Yes 01

No 02

z. (If yes) How old was {CHILD} when [HE/SHE] was first fed beans?

Age [weeks/months]

Don’t know 98

Refused 99

aa. Has [HE/SHE] been given peanut butter

Yes 01

No 02

bb. (If yes) How old was {CHILD} when [HE/SHE] was first fed peanut butter?

Age [weeks/months]

Don’t know 98

Refused 99

cc. Has [HE/SHE] been given meats,, chicken, or fish, including baby food and baby food combination dinners containing these foods?

Yes 01

No 02

dd. (If yes) How old was {CHILD} when [HE/SHE] was first fed meat, chicken, or fish?

Age [weeks/months]

Don’t know 98

Refused 99

ee. Has [HE/SHE] been given salty snacks, such as chips, pretzels, crackers, or other snack foods including baby snacks?

Yes 01

No 02

ff. (If yes) How old was {CHILD} when [HE/SHE] was first fed salty snacks?

Age [weeks/months]

Don’t know 98

Refused 99

gg. Has [HE/SHE] been given sweets, such as cake, cookies, candy, or jam

Yes 01

No 02

hh. (If yes) How old was {CHILD} when [HE/SHE] was first fed sweets?

Age [weeks/months]

Don’t know 98

Refused 99

Next I’m going to ask you some questions about the types of food you buy or make for {CHILD}, how you prepare those foods and feed them to {CHILD}, and what foods you get through WIC.

Source of baby food (homemade or purchased; if purchased, was it all with WIC vouchers or some purchased without WIC vouchers)

7, 9, 11, 13

CF37. For each food category I read to you, please tell me about how much of the food fed to your baby over the past 7 days was store-bought baby food in a jar or container. Baby foods in a jar or container are those sold especially for babies. Foods that are not baby foods in a jar or container include fresh fruit, fruit juices other than those especially sold for babies, foods you prepare especially for the baby, and table food. [Source: FDA IFPS-2, modified]

a. Fruit and vegetable juice

All store-bought baby food 01

Mostly store-bought baby food 02

Some store-bought baby food 03

No store-bought baby food 04

Not fed this food in past 7 days 05

b. Fruit

All store-bought baby food 01

Mostly store-bought baby food 02

Some store-bought baby food 03

No store-bought baby food 04

Not fed this food in past 7 days 05

c. Vegetables

All store-bought baby food 01

Mostly store-bought baby food 02

Some store-bought baby food 03

No store-bought baby food 04

Not fed this food in past 7 days 05

d. Meat, such as beef and chicken

All store-bought baby food 01

Mostly store-bought baby food 02

Some store-bought baby food 03

No store-bought baby food 04

Not fed this food in past 7 days 05

d. Combination dinners

All store-bought baby food 01

Mostly store-bought baby food 02

Some store-bought baby food 03

No store-bought baby food 04

Not fed this food in past 7 days 05

CF38. [If all, mostly or some store-bought baby food indicated above, then ask:] Was all of the store-bought baby food in jars or containers bought with WIC checks, only some with WIC checks, or none with WIC checks? [Source: New Development]

All with WIC checks 01

Some with WIC checks 02

None with WIC checks 03

Don’t know 98

Refused 99

Methods and frequency of methods used to prepare child foods

7, 9, 11, 13

CF39. [If mostly, some, or no store-bought baby food fed in past 7 days from above, ask:] I’m going to read you some ways people prepare homemade food for babies. For each one, please tell me if you do this to make food for {CHILD}. [Source: New Development]

a. Puree, such as in a blender or food processor

Yes 01

No 02

b. Mash, such as with a fork or spoon

Yes 01

No 02

c. Chop or dice

Yes 01

No 02

d. Chew foods yourself before giving to [HIM/HER]

Yes 01

No 02

e. Is there any other way you make food for {CHILD}?

Yes (specify _____________________________) 01

No 02

Method of feeding child (spoon, infant feeder, bottle/modified bottle, etc.)

*3, 5, 7, 9, 11, 13, 15

*only ask if indicated that child is eating solid foods (something other than formula or BM)

CF40. In the past 7 days, have you given {CHILD} any foods with a spoon? [Source: IFPS-1, modified]

Yes 01

No 02

CF41. In the past 7 days, have you given {CHILD} any foods with an infant feeder or with a bottle that has an extra large nipple hole? [Source: IFPS-1, modified]

Yes 01

No 02

Self-feeding during mealtimes

9, 11, 13

CF48. Does {CHILD} feed [HIM/HERSELF] any foods? That is, does {CHILD} pick up these foods and put them in [HIS/HER] mouth without any help? [Source: IFPS-1, modified]

Yes 01

No 02

Don’t know 98

Refused 99

CHILD HEALTH, BEHAVIOR, AND CHILD REARING

Finally I’m going to ask you some questions about your child’s health and behavior.

Health status/conditions

Actions to rectify health conditions

1, 3, 5, 7, 9, 11, 13, 15, 18, 24

CH2. Has the doctor told you that {CHILD} has any long-term medical problems or conditions that may affect what or how [HE/SHE] eats? [Source: FITS 2008, modified]

(Interviewer, if necessary add) These medical problems or conditions may be things like food allergies, diabetes, metabolic disorders such as PKU or galactosemia, gastrointestinal problems such as gastric reflux, other problems like cleft palate or other mouth or facial conditions – any long-term problems that affect the baby’s ability to eat and swallow.

Yes 01

No 02

Don’t Know 98

(If yes) What medical problem or condition does {CHILD} have?

Specify ______________________________________________

CH3. (If yes to health status/conditions in CH2): What are you currently doing to treat this medical problem? [Source: New Development] (Open-ended, Interviewer check all that apply)

Taking her/him to the doctor for treatment 01

Treating him/her at home with medicine 02

Treating him/her at home with something other than

medicine (such as herbal remedies, special teas, or other

forms of treatment) 03

Changing his/her diet 04

Other 05

Don’t Know 98

Refused 99

Child sleep duration/patterns

5, 11, 24

CH9. On a typical day, how much time does your child spend sleeping during the NIGHT, between 7 in the evening and 7 in the morning? [Source: Brief Infant Sleep Questionnaire (BISQ), Sadeh, 2004, modified]

Amount of time [hours, minutes]

CH10. On a typical day, how much time does your child spend sleeping during the DAY, between 7 in the morning and 7 in the evening? [Source: Brief Infant Sleep Questionnaire (BISQ), Sadeh, 2004, modified]

Amount of time [hours, minutes]

CH11. How many times does your child usually wake up during the night, between 7 in the evening and 7 in the morning? [Source: Brief Infant Sleep Questionnaire (BISQ), Sadeh, 2004, modified]

Number of wakings [number]

PARTICIPANT CONTACT INFORMATION UPDATE

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.

CM1. Is your full name still {NAME}?

Yes 01

No 02

(If no, go to a)

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

_____________________________________________

Ask only if still on WIC:

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___________________________________

CM3. 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. 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 30 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.