State, Local and/or Tribal Agencies

Appendix D: Contact Log Abstraction Form

Contact Log Abstraction Form

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 2 hours, 6 minutes 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.

Study ID of WIC Participant
Select one:	 New contact  Update previous contact
Peer counselor name
Date of contact	__ / __ / 20__
Participant’s due date /date of birth	__ / __ / 20__
Mode of contact (select one)	 Telephone  In-person  Other (specify):
Location, if in-person (select one)	 WIC clinic  Hospital  Participant’s home  Other (specify):
Duration of contact	__ __ hours, __ __ minutes
Language(s) spoken	Peer Counselor		WIC Participant
 Both spoke English only	English		English
	Spanish		Spanish
	Other:		Other:
Major topics (check all that apply):
Position/latch Breastfeeding frequency/duration Pros/cons of breastfeeding versus formula Breast discomfort/pain Engorgement Milk supply Supplementation Pumping/expressing milk		Infant’s weight, nutrition, or health Infant’s temperament, sleep patterns, etc. Mother’s health Mother returning to work/school Other caregiver’s bonding with infant Referral to lactation consultant Other breastfeeding-related topic (specify):
Mother reports that family attitude towards breastfeeding is:
Very supportive Somewhat supportive Somewhat unsupportive Very unsupportive		Don’t know REFUSED
New phone number or address for Study Participant?1  Yes

Enter next contact log for

SAME Participant

Enter contact log for a

different Participant

1 To maintain the privacy of the study participant, any new phone/address will be collected separately (i.e., by correcting the exisiting Study Enrollment Form for the study participant).

Abt Associates Inc. Contact Log Abstraction Form Draft 02