State, Local and/or Tribal Agencies

OMB Clearance Number: 0584-0548 Expiration Date: xx/xx/20xx

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0548. The time required to complete this information collection is estimated to average 30 seconds (half of one minute) per response. If you have any comments concerning the accuracy of time estimates or suggestions for improving this form, please contact: U. S. Department of Agriculture, Food and Nutrition Service, Office of Research & Analysis, Room 1014, Alexandria, VA 22302.

INVITATION TRACKING FORM, WIC Peer Counseling Study (Phase 2)

INSTRUCTIONS: For each WIC participant who is Eligible Now:

1. Invite her to participate in the Study

2. Record today’s date the woman’s FIRST NAME ONLY, and your name on the table below.

3. Follow the steps below based on her decision about Study Participation (Declined, Undecided, or Interested):

1. DECLINED (does not want to participate in the Study):

1. Check “Declined” and write your name in the last column

2. Ask her to complete Decline Form (she does not have to).

2. UNDECIDED (wants to think it over):

1. Check “UNDECIDED”

2. Give her a copy of the Consent Form and a Study Brochure.

3. Point out the ways that she can get more information (listed on the Consent Form and the Study Brochure).

4. Remind her that there is no obligation to participate in the study. Remind her that she will receive all of the WIC benefits she is eligible to receive whether or not she decides to take part in the study.

5. Tell her that you will call her within two days to ask for her decision about the study. Ask for best times to reach her and any times she does not want to be called.

6. Record her contact information and schedule a call-back date & time(s).

3. INTERESTED (wants to participate in the Study):

1. Administer Consent Form.

2. If she becomes unsure after reading the Consent Form, GO TO B above

3. If she declines to sign the Consent Form , GO TO A above

4. If she signs the Consent Form, Check “ENROLLED” and complete the Study Enrollment Form.

Invitation Tracking Form Date Started: xx/xx/20xx						For Undecided, Followup Results?
Date	Name of WIC staffperson	Invited WIC Participant’s First Name	Enrolled	Declined	Undecided	E	D	No Decision	Date:
		subtotal				E	D	ND	D+ND=
			E	D+ND
		TOTAL

After filling all 13 rows, start a new Invitation Tracking Form. Abt Associates will calculate subtotal and TOTAL.

If 3 or more unsuccessful attempts to contact, or a woman is still undecided, mark Unenrolled and discontinue follow-up.