State, Local and/or Tribal Agencies

Appendix B: Peer Counselor Background
Questionnaire

Abt Associates Inc.

Peer Counselor Background Questionnaire Draft 02

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OMB Control#: 0584-0548
Expiration Date: xx/xx/20xx

Breastfeeding Peer Counselor Questionnaire
As part of the WIC Breastfeeding Peer Counseling Study for the U.S. Department of Agriculture,
Food and Nutrition Service (FNS), we are asking Peer Counselors participating in the study to
complete this short questionnaire. The purpose of this questionnaire is to learn about the
characteristics of breastfeeding peer counselors who work with WIC participants. We estimate
that it will take you 15 minutes to complete this questionnaire.
You and your WIC agency’s name and location will not be identified in reports prepared for this
study or in data files provided to FNS. None of your responses will be released in a form that
identifies you or any staff member at your agency by name, except as required by law. Please
note that this study is not part of an audit or management review of WIC.
Your participation in this questionnaire is completely voluntary. You are not required to
complete this questionnaire and no one at your WIC agency will penalize you if you decide not
to answer these questions. To help us protect your privacy, please read and follow the
instructions below.

INSTRUCTIONS
1. Please read and sign the WHITE copy of the Consent Form on the next page before
answering any items on this questionnaire. If you do not wish to participate, do not sign
the consent form.
2. When you finish please put the WHITE copy of the Consent Form and the questionnaire
in the Study Envelope.
3. Seal the envelope closed and then give it to your supervisor. If you prefer, you may
drop it in any U.S. Postal Service mailbox. No postage is required.

OMB Clearance Number: 0584-0548
Expiration Date: mm/dd/20xx
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 control number. The valid OMB control number for this
collection is 0584-0548. The time required to complete this information collection is estimated to average
15 minutes per response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collected.

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OMB Control#: 0584-0548
Expiration Date: xx/xx/20xx

Consent Form
Peer Counselor Questionnaire
for the WIC Breastfeeding Peer Counseling Study
Your participation in this questionnaire is completely voluntary. You are not required to
complete this questionnaire. If you if you decide not to answer these questions, there will be
no adverse consequences for you. You may leave blank any questions you do not wish to
answer.
The purpose of this questionnaire is to learn about the characteristics of breastfeeding peer
counselors who work with WIC participants. If you choose to participate, the risk of any harm
to you is minimal. You may not benefit directly by answering these questions. However, you
may help the Food and Nutrition Service (FNS) learn more about how WIC can best support
breastfeeding among WIC participants.
You and your WIC agency’s name and location will not be identified in reports prepared for
this study or in data files provided to FNS. Your responses will be used for statistical purposes.
None of your responses will be released in a form that identifies you or any staff member at
your agency by name, except as required by law. Please note that this study is not part of an
audit or management review of WIC. To protect your privacy, we will separate your
questionnaire from other materials that have your name. We will store your consent form and
questionnaire in two separate locations that are secure. We will keep track of your responses
using a study identification number (study ID) and not your name. We will enter your responses
and your study ID number into a computer database. Your name will not be stored in the same
database with your responses.
This questionnaire and the WIC Breastfeeding Peer Counseling study have been reviewed and
approved by Abt Associates’ Institutional Review Board (IRB) for research with human
participants. The IRB study approval number is xxxx. If you have questions about your rights as
a research participant, please contact [email protected], or call the IRB Administrator (tollfree) at (xxx) xxx-xxxx.
I have read and understood the above information and I agree to participate in completing the
enclosed Peer Counselor Questionnaire for the WIC Breastfeeding Peer Counseling Study.

Signature:

Print your name:

Date:

RETURN THIS COPY (White copy) with your Questionnaire

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PC-ID 0x-nn

OMB Control#: 0584-0548
Expiration Date: xx/xx/20xx

Consent Form
Peer Counselor Questionnaire
for the WIC Breastfeeding Peer Counseling Study
Your participation in this questionnaire is completely voluntary. You are not required to
complete this questionnaire. If you if you decide not to answer these questions, there will be
no adverse consequences for you. You may leave blank any questions you do not wish to
answer.
The purpose of this questionnaire is to learn about the characteristics of breastfeeding peer
counselors who work with WIC participants. If you choose to participate, the risk of any harm
to you is minimal. You may not benefit directly by answering these questions. However, you
may help the Food and Nutrition Service (FNS) learn more about how WIC can best support
breastfeeding among WIC participants.
You and your WIC agency’s name and location will not be identified in reports prepared for
this study or in data files provided to FNS. Your responses will be used for statistical purposes.
None of your responses will be released in a form that identifies you or any staff member at
your agency by name, except as required by law. Please note that this study is not part of an
audit or management review of WIC. To protect your privacy, we will separate your
questionnaire from other materials that have your name. We will store your consent form and
questionnaire in two separate locations that are secure. We will keep track of your responses
using a study identification number (study ID) and not your name. We will enter your responses
and your study ID number into a computer database. Your name will not be stored in the same
database with your responses.
This questionnaire and the WIC Breastfeeding Peer Counseling study have been reviewed and approved
by Abt Associates’ Institutional Review Board (IRB) for research with human participants. The IRB study
approval number is xxxx. If you have questions about your rights as a research participant, please contact
[email protected], or call the IRB Administrator (toll-free) at (xxx) xxx-xxxx.

KEEP THIS COPY (Yellow copy) for your records

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Section A. Your role as a Breastfeeding Peer Counselor
1. Did you sign the Consent Form on the previous page? Mark one answer.
1 YES

Go to Question 2.

2 NO

Please sign the Consent Form before marking any answers below.

2. What is today’s date?
Month

Day

Year

3. How long have you been a Breastfeeding Peer Counselor?
Year(s). If less than 1 year, how many months?
Months

4. Thinking about last month, about how many hours per week, on average, did you work
as a breastfeeding peer counselor?
Hours per week, on average, last month

Please continue to the next page . . .

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Section B. Languages you speak
6. Do you speak any languages other than English? Mark one answer.
1 YES

Go to QUESTION 7.

2 NO

SKIP to QUESTION 9.

7. 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
2 Other – Specify

1

Source: American Community Survey, 2005

8. How well do you speak English? Mark one response.
Very Well
I speak English
1

Well
2

Not Well
3

Not at all
4

Source: American Community Survey, 2005

Section C. Your education and training
9. Do you have any of the following certifications? Mark YES or NO for each.
YES NO
1 2 Certified Breastfeeding Counselor (CBC)
1

2 Certified Lactation Counselor (CLC)

1

2 Certified Lactation Educator (CLE)

1

2 Registered Lactation Consultant (RLC); that is, certification from the
International Board of Lactation Consultant Examiners (IBLCE)

1

2 Other breastfeeding or lactation certification – Specify

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Section D. Demographic Information
10. 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)
11. What is your ethnicity? Mark one answer.
1 Hispanic or Latino
2 Not Hispanic or Latino
12. 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
13. 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
14.

When were you born?
Month

Day

Year

15. Including yourself, how many people live in your household?
Total number of people, including self, in your household

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16. How many of these people living in your household are:
Adults aged 18 and older?
Children between the ages of 6 and 18?
Children under 6 years of age?

17. 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
5
6
7
8

Between $20,001 - $25,000
Between $25,001 - $30,000
Between $30,001 - $35,000
Between $35,001 - $40,000
More than $40,000

18. 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 – we appreciate your participation.
Remember to do the following:
A. If you answered any questions, please check to make sure you signed the WHITE
Consent Form. Return the WHITE copy and keep the yellow copy.
B. Place the WHITE consent form and the questionnaire in the envelope provided. (You
may keep the yellow copy of the consent form. It has information about how to contact
us if you have questions about the study.)
C. Be sure to seal the envelope closed and then return it to your supervisor at your local
WIC agency. If you prefer, you may drop the sealed envelope in any US post office
mailbox.

Thank you.

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