Information Collection

WIC Participant

IC 203577 under ICR 201404-0584-005 · OMB 0584-0580.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0580 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
App.E.1_Eng.Screening_Enrollment.Participant.InterviewwithFoodSecurity v2.docx	Other-App.E.1_Eng.Screening_Enrollme
App.E.2_Span.Screening.Enrollment.Participant.InterviewwithFoodSecurityv2.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 -Food Securityv2.docx	Other-App.M.1_Eng.7 Month Participan
App.M.2_Span.7 Month Participant Interview Food Securityv2.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-Food Securityv2.docx	Other-App.P.1_Eng.13 Month Participa
App.P.2_Span.13 Month Participant Interview Food Securityv2.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 Food Securityv2.docx	Other-App.R.1_Eng.18 Month Participa
App.R.2_Span.18 Month Participant Interview Food Securityv2.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
AppYY1_HIPAAletter_English.docx	Other-HIPAA Consent Letter English
AppYY2_HIPAAletter_Spanish.docx	Other-HIPAA Consent Letter Spanish
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
0584-0580 Change Justification HIPAA Incentive memo 4-10-2014 final.pdf Change Justification Memo HIPAA Incentive	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

WIC Participant

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-App.E.1_Eng.Screening_Enrollment.Participant.Interview.	App.E.1_Eng.Screening_Enrollment.Participant.InterviewwithFoodSecurity v2.docx	Yes	Yes	Fillable Fileable
Other-App.E.2_Span.Screening_Enrollment.Participant.Interview	App.E.2_Span.Screening.Enrollment.Participant.InterviewwithFoodSecurityv2.docx	Yes	Yes	Fillable Fileable
Other-App.F.1_Eng.Prenatal Enrollment Package.Letter	App.F.1_Eng.Prenatal Enrollment Package.Letter.docx	No		Paper Only
Other-App.F.2_Span.Prenatal Enrollment Package.Letter	App.F.2_Span Prenatal Enrollment Package.Letter.docx	No		Paper Only
Other-App.G 1_Eng Postnatal Enrollment Package Letter	App.G 1_Eng Postnatal Enrollment Package Letter.V2.docx	No		Paper Only
Other-App.G 2_Span Postnatal Enrollment Package Letter	App.G 2_Span Postnatal Enrollment Package Letter.V2.docx	No		Paper Only
Other-App.I.1_Eng.Prental Participant Interview	App.I.1_Eng.Prental Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.I.2_Span.Prenatal Participant Interview	App.I.2_Span.Prenatal Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.J.1_Eng.1 Month Participant Interview	App.J.1_Eng.1 Month Participant Interview (revised).docx	Yes	Yes	Fillable Fileable
Other-App.J.2_Span.1 Month Participant Interview	App.J.2_Span.1 Month Participant Interview (revised).docx	Yes	Yes	Fillable Fileable
Other-App.K.1_Eng.3 Month Participant Interview	App.K.1_Eng.3 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.K.2_Span.3 Month Participant Interview	App.K.2_Span.3 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.L.1_Eng.5 Month Participant Interview	App.L.1_Eng.5 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.L.2_Span.5 Month Participant Interview	App.L.2_Span.5 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.M.1_Eng.7 Month Participant Interview	App.M.1_Eng.7 Month Participant Interview -Food Securityv2.docx	Yes	Yes	Fillable Fileable
Other-App V 2_Span Automated Multiple Pass Method 24HR Module Screenshots	App V 2_Span Automated Multiple Pass Method 24HR Module Screenshots.pdf	Yes	Yes	Fillable Fileable
Other-HIPAA Consent Letter English	AppYY1_HIPAAletter_English.docx	No		Paper Only
Other-HIPAA Consent Letter Spanish	AppYY2_HIPAAletter_Spanish.docx	No		Paper Only
Other-App.EE.2_Span.Home Health Visit Script.LengthWeight	App.EE.2_Span.Home Health Visit Script.LengthWeight.docx	No		Paper Only
Other-App.T.1_Eng.Baseline module.Participant.Interview	App.T.1_Eng.Baseline module.Participant.Interview.docx	Yes	Yes	Fillable Fileable
Other-App.T.2_Span.Baseline module.Participant.Interview	App.T.2_Span.Baseline module.Participant.Interview.docx	Yes	Yes	Fillable Fileable
Other-App.U.1_Eng.New Caregiver module.Participant.Interview	App.U.1_Eng.New Caregiver module.Participant.Interview.docx	Yes	Yes	Fillable Fileable
Other-App.U.2_Span.New Caregiver module.Participant.Interview	App.U.2_Span.New Caregiver module.Participant.Interview.docx	Yes	Yes	Fillable Fileable
Other-App.V.1 Eng Automated Multiple Pass Method 24HR.Module.Screenshots (revised)	App.V.1 Eng Automated Multiple Pass Method 24HR.Module.Screenshots (revised).pdf	Yes	Yes	Fillable Fileable
Other-App.DD.1_Eng.HomeHealthcareAgency.LengthWeight.Form	App.DD.1_Eng.HomeHealthcareAgency.LengthWeight.Form.docx	No		Paper Only
Other-App.DD.2_Span.HomeHealthcareAgency.LengthWeight.Form	App.DD.2_Span.HomeHealthcareAgency.LengthWeight.Form.V2.docx	No		Paper Only
Other-App.EE.1_Eng.Home Health Visit Script.LengthWeight	App.EE.1_Eng.Home Health Visit Script.LengthWeight.docx	No		Paper Only
Other-App.M.2_Span.7 Month Participant Interview	App.M.2_Span.7 Month Participant Interview Food Securityv2.docx	Yes	Yes	Fillable Fileable
Other-App.N.1_Eng.9 Month Participant Interview	App.N.1_Eng.9 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.N.2_Span.9 Month Participant Interview	App.N.2_Span.9 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.O.1_Eng.11 Month Participant Interview	App.O.1_Eng.11 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.O.2_Span.11 Month Participant Interview	App.O.2_Span.11 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.P.1_Eng.13 Month Participant Interview	App.P.1_Eng.13 Month Participant Interview-Food Securityv2.docx	Yes	Yes	Fillable Fileable
Other-App.P.2_Span.13 Month Participant Interview	App.P.2_Span.13 Month Participant Interview Food Securityv2.docx	Yes	Yes	Fillable Fileable
Other-App.Q.1_Eng.15 Month Participant Interview	App.Q.1_Eng.15 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.Q.2_Span.15 Month Participant Interview	App.Q.2_Span.15 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.R.1_Eng.18 Month Participant Interview	App.R.1_Eng.18 Month Participant Interview Food Securityv2.docx	Yes	Yes	Fillable Fileable
Other-App.R.2_Span.18 Month Participant Interview	App.R.2_Span.18 Month Participant Interview Food Securityv2.docx	Yes	Yes	Fillable Fileable
Other-App.S.1_Eng.24 Month Participant Interview	App.S.1_Eng.24 Month Participant Interview.docx	Yes	Yes	Fillable Fileable
Other-App.S.2_Span.24 Month Participant Interview	App.S.2_Span.24 Month Participant Interview.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title: Privacy Act of 1974

FR Citation: 5 FR 552

Number of Respondents: 4,468

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	20,555	1,888	18,667
Annual IC Time Burden (Hours)	4,463	33	4,430
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.