State and Local WIC-Screener, Staff, Personnel

WIC Infant and Toddler Feeding Practices Study-2

App.D.1_Eng.Participant Referral Form

State and Local WIC-Screener, Staff, Personnel

OMB: 0584-0580

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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


  1. Pregnant/Está embarazada: □ YES/ □ NO


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


  1. 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 :

_______________________________


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


  1. 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.

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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.


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AuthorBibi Gollapudi
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File Created2021-01-27

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