I/H WIC Participants

Appendix C3: Decline Form

Decline 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 3 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.

We respect your decision not to participate in the study. At the same time, we are interested in seeing if there are any differences between women who choose not to participate in the study and those who participate in the study. We would like you to complete this short questionnaire. You do not have to complete this questionnaire, and you may skip any questions that you prefer not to answer. Please do not put your name on this questionnaire.

1. What are the main reasons you chose not to participate? Check all that apply.
	1	I don’t think the study will benefit me or my baby
	2	I am too busy
	3	I get asked to do surveys too often
	4	I’m concerned about my privacy
	9	O ther – Specify

2. Do you speak any languages other than English? Mark one answer.
	1	YES	Go to QUESTION 3.
	2	NO	S KIP to QUESTION 4 on Page 2.

3. What other language(s) do you speak? Mark YES or NO for each.
	YES	NO
	1	2	Spanish
	1	2	Chinese (Mandarin, Cantonese, or other Chinese dialect)
	1	2	Tagalog
	1	2	French
	1	2	Vietnamese
	1	2	O ther – Specify

4. What is the highest grade or level of school you completed? Mark one answer.
	1	Some high school
	2	High school diploma or GED
	3	Some college
	4	2-year college degree (e.g., Associate’s degree)
	5	4-year college degree (e.g., Bachelor’s degree)
	6	More than 4-year college degree (e.g., some graduate school, Master’s degree)

5. What is your ethnicity? Mark one answer.
	1	Hispanic or Latino
	2	Not Hispanic or Latino

6. What is your race? Check one or more.
	1	American Indian or Alaska native
	1	Asian
	1	Black or African American
	1	Native Hawaiian or other Pacific Islander
	1	White

7. Where were you born? Mark one answer.
	1	In the United States (one of the 50 states or the District of Columbia)
	2	In one of the the U.S. Territories (Puerto Rico, Guam, American Samoa, US Virgin Islands, Mariana Islands or Solomon Islands)
	3	In another country

8. How old are you? Mark one answer.
	1	18 to 25 years
	2	26 to 30 years
	3	31 to 35 years
	4	36 to 40 years
	5	41 years or older

9. What is your total household income? Mark one answer.
	1	Less than $10,000
	2	Between $10,001 - $15,000
	3	Between $15,001 - $20,000
	4	Between $20,001 - $25,000
	5	Between $25,001 - $30,000
	6	Between $30,001 - $35,000
	7	Between $35,001 - $40,000
	8	More than $40,000

10. Have you ever received any of the following? Check all that apply.
	1	SNAP Benefits (formerly Food Stamps)
	1	TANF or cash assistance
	1	Medicaid
	1	Welfare
	1	Not sure/don’t know

THANK YOU.

Abt Associates Inc. Decline Form