WIC NE State & Local - Phase I

APPENDIX B.1:
Local Agency Web Survey—English

OMB Control Number: 0584-XXXX
Expiration date: XX/XX/XXXX

WIC Nutrition Education Study

Local Agency Survey

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 number. The valid OMB control number for this information collection is 0584-XXXX. The time required to ‎complete this information collection is estimated to average 45 minutes per response, including the time for reviewing instructions, ‎searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of ‎information.

Thank you for completing the Local Agency Survey for the WIC Nutrition Education Study (NEST). This survey is being conducted for the USDA, Food and Nutrition Service (FNS) to collect information that will provide a description of how WIC agencies provide nutrition education to participants. Your local agency/program was randomly selected as part of a group of about 1,000 agencies to represent all local WIC agencies in the nation. Your responses to the survey questions will be combined with responses from the other agencies to develop a comprehensive picture of the methods, staffing, resources, and facilities used to deliver nutrition education in local WIC sites. Your input is critical in achieving the study’s goal of providing a comprehensive description of WIC nutrition education. The information you provide will help strengthen and enhance WIC nutrition education efforts and highlight the efforts across the country to promote healthy eating and physical activity practices among WIC participants.

Local agencies, sites, and individual respondent names will not be identified in any study reports or publications. Although survey responses will be identifiable to FNS, the responses will not be used for compliance or monitoring activities.

Please complete the survey by MM/DD/YYYY.

Most questions include a “button” [show icon for selection button] or a box [show icon for box] to select a response. Some questions require that you enter numbers or text responses. We recommend that you review the questions before beginning the survey so that you can obtain any information needed to respond. [Click here] to download and print a copy of the survey. The survey will take about 45 minutes to complete.

Nutrition Education Survey Help Desk

If you have any problems completing the survey, please contact:

[Toll-free phone number]

[E-mail address]

WIC Sites

For all survey questions, nutrition education includes breastfeeding education.

1. How many WIC sites operated by your local agency/program provide nutrition education? (Count any facility or location where your local agency provides nutrition education including full-time, part-time, temporary, satellite, and mobile sites.)

Programming Note: Allow entry of number up to 99.

Number of sites _______

2. Of the WIC sites that provide nutrition education, how many are located in each type of facility listed below? (Count each site once in the type of facility that is the best match. Consider the organization that owns/operates the site’s facility, which may not be the organization that operates the WIC program.)

Type of Facility	Number of Sites
City, county, state or U.S. territory health department (not including government-run hospitals)	____
Government facility that does not provide public health or healthcare services (e.g., community center, government service center, courthouse)	____
Indian Health Service (IHS) clinic or hospital	____
Federally Qualified Health Center (FQHC)	____
Nonprofit health center or medical clinic (not including IHS or FQHC)	____
Hospital (not including IHS hospital)	____
Stand-alone WIC site (e.g., leased space in shopping center or other commercial space)	____
Nonprofit community services agency facility (e.g., Economic Opportunity Commission, Community Action Agency)	____
School or Head Start facility	____
Faith-based facility	____
Mobile van	____
Other (describe):	____
Total number of sites	____

For question 2 and all subsequent survey questions that include a response option of “other” in a table, display the following question when “other” is selected as a response: You selected “other” as a response to the question above. Please enter an explanation of “other” in this box. [include a text entry box allowing for entry of 200 characters ]

3. About what percentage of participants served by your local agency speak a language other than English as their primary language? (Include participants served at all sites. Please estimate if this information is not readily available.)

• None

• 1–5%

• 6–10%

• 11–30%

• 31–50%

• 51–70%

• 71–90%

• 91–100%

Programming Note: If response to Question 3 is “None,” then skip Question 4. Provide pick list allowing for multiple selections for response to Question 4.

4. Other than English, what languages are spoken by participants served by your local agency? (Select all that apply.)

• Spanish

• Arabic

• American Sign Language

• Cambodian/Khmer

• Cantonese/Mandarin

• Farsi

• French/Creole

• Fulani

• Hindi

• Hmong

• Korean

• Laotian

• Portuguese

• Punjabi

• Russian

• Somali

• Swahili

• Tamil

• Tagalog

• Urdu

• Vietnamese

• Other (describe):

High-Risk Participants

5. Does your State agency have nutrition education policies and/or protocols for participants that are identified as high risk?

• Yes

• No

6. Does your local agency classify participants into nutrition risk levels (e.g., high risk, not high risk)?

• Yes

• No

7. What, if any, modifications to nutrition education does your local agency make based on participant’s risk levels or nutrition risks? For this question, “high risk” includes participants identified as high risk and/or participants with nutrition risks requiring special attention. (Select all that apply.)

• There are no modifications to nutrition education for high-risk participants.

• High-risk participants receive more nutrition education contacts.

• High-risk participants receive nutrition education from a dietitian, nutritionist, or other health professional.

• High-risk participants are given longer appointment times.

• High-risk participants receive one-on-one counseling instead of group sessions or other types of education.

• High-risk participants receive more detailed and individualized care plans.

• There is more follow-up on referrals for high-risk participants.

• Other (describe):

Nutrition Education Contacts and Methods

8. How many nutrition education contacts does your local agency plan for the following participant categories and time periods? While the number of contacts varies based on individual needs, enter the number that is planned for the majority of participants in the category. (Count all contacts planned during the certification period beginning with the certification visit. Enter NA for any category/time period that is not applicable to your local agency.)

Participant Category and Time Periods	Number of Nutrition Education Contacts
	Participants Who Are NOT High Risk	Participants Who Are High Risk*
Prenatal woman, enrolling in 1st trimester	__	__
Prenatal woman, enrolling in 2nd trimester	__	__
Prenatal woman, enrolling in 3rd trimester	__	__
Breastfeeding woman, 6-month certification period	__	__
Breastfeeding woman, 12-month certification period	__	__
Postpartum woman, not breastfeeding	__	__
Infant, 6-month certification period	__	__
Infant, 12-month certification period	__	__
Child, 6-month certification period	__	__
Child, 12-month certification period	__	__

*High risk includes participants identified as high risk and/or participants with nutrition risks requiring special attention.

9. During what types of visits does your local agency provide nutrition education contacts? (Select all that apply.)

• Certification visit (e.g., enrollment, recertification)

• Mid-certification visit (e.g., prenatal trimester visit, infant/child mid-certification, breastfeeding mid-certification)

• Secondary education follow-up visit (e.g., group classes, food issuance/pick-up education, breastfeeding follow-up, low risk follow-up)

• High-risk follow-up visit (e.g., nutritionist visit, nutrition counseling visit, high-risk group classes)

• Other (describe):

Programming Note: Display answers from Question 9 in first column of table below in Question 10. If response to Question 9 includes “Certification visit,” then display all four types of certification in table. If “Secondary education” is selected, display both types of secondary education. Also, display answers from Question 9 in the table on Question 11 by including only columns for visit types selected.

10. How much time is planned for providing nutrition education during each type of visit? (Select one response for each type of visit.)

Type of Visit	Less than 5 Min	5–10 Min	11–20 Min	21–30 Min	31–45 Min	46–60 Min	More than 60 Min	NA	Don’t Know
Enrollment certification									
Recertification — Not high risk, 1 person									
Recertification — High risk, 1 person									
Recertification — 2 or more family members									
Mid-certification									
Secondary education follow-up (individual)									
Secondary education follow-up (group)									
High-risk follow-up									
Other									

11. What methods are used to provide nutrition education? (Select all methods that are used for each type of visit.)

Method	Enrollment Certification	Recertification	Mid-certification	Secondary Education Follow-up	High-Risk Follow-up	Other
One-on-one counseling: Face to face (in WIC site)						
One-on-one counseling: Telephone						
One-on-one counseling: Video conferencing						
Group education sessions						
Technology-based nutrition education used by participants at site (e.g., computer, kiosk, tablet)						
Technology-based nutrition education used by participants offsite via Internet (e.g., Internet-based nutrition education modules)						
Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules)						

Programming Note: For question 12, display only if “group education sessions” and/or “technology-based nutrition education used offsite” were selected for Question 11.

12. About what percentage of participants served at all sites operated by your local agency receive nutrition education through the method(s) included below? (Please estimate if this information is not readily available. Select one response for each method.)

1. Group education sessions

• None

• <10%

• 11-39%

• 40-59%

• 60-89%

• 90% or more

• Don’t know

2. Technology-based nutrition education used by participants offsite (e.g., Internet-based nutrition education modules)

• None

• <10%

• 11-39%

• 40-59%

• 60-89%

• 90% or more

• Don’t know

Nutrition Education Reinforcement Practices and Sources

13. How does your local agency follow up with participants about their goals or concerns discussed during nutrition contacts (e.g., breastfeeding issues, weight-related goals)? (Select all that apply.)

• Follow-up occurs at subsequent WIC visits

• Telephone calls

• Emails

• Text messages

• Video conferencing

• Other (describe):

14. What methods does your local agency use to reinforce the information provided in nutrition education sessions? (Select all that apply for each type of method.)

Onsite Methods	Offsite Methods
 Brochures or written materials	 Email messages with nutrition education content
 Bulletin boards with nutrition information	 Grocery store tours
 Computer, kiosk, or tablet computer at site	 Monthly or quarterly nutrition newsletter sent home
 Cooking demonstrations	 Nutrition education DVDs/videos sent home
 Display tables with nutrition information	 Social media (e.g., Facebook, Twitter)
 Educational props (e.g., food containers, breastfeeding dolls, physical activity items)	 Technology-based education used outside of site (e.g. Internet modules)
 Food tasting	 Telephone calls with nutrition education content
 Nutrition education DVDs/videos viewed at site	 Text messages with nutrition education content
 Support groups (e.g., parenting or breastfeeding group)	 Other:
 Other:

15. What is the source of nutrition education materials (e.g., lesson plans, pamphlets, videos) used by your local agency? (Select all that apply.)

• Your State agency

• Your local agency

• Individual WIC sites

• National WIC Works Resource system

• USDA, Food and Nutrition Service (FNS)

• Non-WIC sources

• Other (describe):

Programming Note: If responses to Question 11 do not include “Technology-based nutrition education used at site” or “Technology-based nutrition education used offsite via Internet,” then skip Question 16.

16. What is the source of the technology-based nutrition education used by your local agency? (Select all that apply.)

• Developed or provided by your State agency

• Developed by your local agency

• Developed by individual WIC sites

• Downloaded or obtained from national WIC Works Resource system

• Developed by USDA, Food and Nutrition Service

• Developed by non-WIC sources

• Other (describe):

• Don’t know

Policies on Staff Qualifications and Training

The next questions ask about staff your local agency employs to provide nutrition education and your local agency hiring policies for minimum education, credentials, and training requirements.

17. Who provides nutrition education at your local agency? (Select all job classifications/types that apply.)

• WIC director/coordinator

• Site/clinic supervisor

• Registered dietitian (RD)

• Degreed nutritionist, not RD

• Trained nutrition paraprofessional (e.g., nutrition assistant, nutrition aid, competent paraprofessional authority, diet technician, social services technician)

• Nurse

• Nutrition education coordinator

• Administrative/clerical/support staff

• Lactation consultant/WIC-designated breastfeeding expert

• Breastfeeding coordinator

• Breastfeeding peer counselor

• Other (describe):

18. Which best describes how policies are set for the minimum educational and/or credential requirements for staff who provide nutrition education?

• Educational/credential requirements are set by State agency

• Education/credential requirements are set by local agency

• Some requirements are set by State agency and some by local agency

• There are no minimum educational/credential requirements

• Don’t know

Programming Note: Display only job classifications/types selected in Question 17 in Questions 19-21.

19. At your local agency, what is the policy for the minimum educational requirements for staff who provide nutrition education? (Select one response for each job classification/type of staff.)

Job Classification/Type of Staff who Provide Nutrition Education	Degree Required				No Minimum Requirement
	High School Diploma/GED	Associate’s Degree	Bachelor’s Degree	Graduate Degree
WIC director/coordinator					
Site/clinic supervisor					
Registered dietitian (RD)					
Degreed nutritionist, not RD					
Trained nutrition paraprofessional					
Nurse					
Nutrition education coordinator					
Administrative/clerical/support staff					
Lactation consultant/WIC-designated breastfeeding expert					
Breastfeeding coordinator					
Breastfeeding peer counselor					
Other:					

20. At your local agency, what credentials are required for staff who provide nutrition education? (Select all that apply for each job classification/type of staff.)

Definition: Credential is a certification from a professional association or training program.

Job Classification/Type of Staff who Provide Nutrition Education	Credential(s)
	RD	LD/LN	DTR	RN	LPN	IBCLC	CLC/CLE/CLEC	CMA	No Credential Requirements
WIC director/coordinator									
Site/clinic supervisor									
Registered dietitian (RD)									
Degreed nutritionist, not RD									
Trained nutrition paraprofessional									
Nurse									
Nutrition education coordinator									
Administrative/clerical/support staff									
Lactation consultant/WIC-designated breastfeeding expert									
Breastfeeding coordinator									
Breastfeeding peer counselor									
Other:									

RD = Registered Dietitian; LD/LN = Licensed Dietitian/Licensed Nutritionist; DTR = Dietetic Technician, Registered; RN = Registered Nurse; LPN = Licensed Practical Nurse; IBCLC = International Board Certified Lactation Consultant; CLC/CLE/CLEC = Certified Lactation Consultant/Certified Lactation Educator/Certified Lactation Educator & Counselor; CMA = Certified Medical Assistant

21. At your local agency, what training is required for new employees who provide nutrition education? (Select all that apply for each job classification/type of staff.)

Job Classification/Type of Staff who Provide Nutrition Education	Required Training
	Competency-Based* or Certification Program	State-Administered Training Program (e.g., State training center, regional training)	Self-Paced Training Modules (e.g., paper, online, DVD)	On-the-Job with Observation	Other	No Minimum Requirements
WIC director/coordinator						
Site/clinic supervisor						
Registered dietitian (RD)						
Degreed nutritionist, not RD						
Trained nutrition paraprofessional						
Nurse						
Nutrition education coordinator						
Administrative/clerical/support staff						
Lactation consultant/WIC-designated breastfeeding expert						
Breastfeeding coordinator						
Breastfeeding peer counselor						
Other:						

*An educational approach based on a predetermined set of knowledge, skills, and abilities that the student is expected to accomplish.

Staff Training

For the next three questions, “nutrition education training” refers to training on methods (e.g., learner-centered education) as well as topics (e.g., importance of whole grains).

22. Does your local agency have a policy that requires ongoing training on nutrition education for any staff members who provide it? Do not include continuing education required for maintaining a credential. (Select all that apply.)

• Yes, local agency requires specific number of hours per month

• Yes, local agency requires specific number of hours per year

• Yes, local agency implements State agency requirements for ongoing training

• No local agency policy requiring ongoing training

23. How is ongoing nutrition education training usually provided to staff? (Select all that apply.)

• National/State/regional conferences or workshops

• Training sessions/courses at State training center

• In-person training sessions (e.g., conferences, workshops) provided by your local agency

• In-person training sessions (e.g., conferences, workshops) provided by other local agencies or programs

• State or local agency webinars

• Self-study training modules or courses (online or print copy)

• Training provided during local agency or site staff meetings

• Individual staff mentoring/coaching

• Other (describe):

24. About how many hours of nutrition education training does your local agency provide each year to each person who provides nutrition education? (Select the response that represents the approximate hours per staff member per year.)

• None

• 1–6 hours

• 7–12 hours

• 13–18 hours

• 19–24 hours

• 25 or more hours

25. In the past 24 months, about what percentage of staff members who provide nutrition education were trained in the topics listed below? Include training that was provided by your local agency, State agency, and any outside training. (Please estimate if this information is not readily available. Select one response for each topic.)

Topics	None	1–25%	26–50%	51–75%	76–100%	Don’t Know
3-step counseling						
Facilitated group discussion						
Motivational interviewing						
Communication skills						
Goal setting						
Emotion-based counseling						
Skills related to Value Enhanced Nutrition Assessment (VENA) and/or participant/learner-centered education						
Training on a foreign language (e.g., Spanish)						
Other:						

Design and Oversight of Nutrition Education

26. How does your local agency design and oversee implementation of nutrition education? (Select all that apply.)

Design includes developing lesson plans, protocols, and materials for nutrition education. Oversee includes directing, managing, or supervising the implementation of nutrition education.

• One individual designs and oversees nutrition education for all sites.

• A team of two or more individuals designs and oversees nutrition education for all sites.

• Each site designs and oversees its own nutrition education.

• State agency designs nutrition education and local agency oversees nutrition education.

• State agency designs and oversees nutrition education.

• Other (describe):

Programming Note: If response to Question 26 is “State agency designs and oversees nutrition education,” then skip Questions 27-29.

27. Who designs and/or oversees nutrition education at your local agency? (Select all job classifications/types that apply.)

• WIC director/coordinator

• Site/clinic supervisor

• Registered dietitian (RD)

• Degreed nutritionist, not RD

• Trained nutrition paraprofessional (e.g., nutrition assistant, nutrition aid, competent paraprofessional authority, diet technician, social services technician)

• Nurse

• Nutrition education coordinator

• Lactation consultant/WIC-designated breastfeeding expert

• Other (describe):

28. Are you one of the individuals who designs and/or oversees nutrition education at your local agency?

• Yes

• No

Programming Note: If response to Question 28 is “No,” then skip Question 29.

29. How many years of work experience do you have at WIC designing and/or overseeing nutrition education?

• Less than 1 year

• 1–3 years

• 4–6 years

• 7–10 years

• 11–20 years

• More than 20 years

Coordination with Other Programs and Services

30. Does your local agency receive funding, materials, or “in-kind” support (e.g., space, staff, materials) for nutrition education or breastfeeding from any source other than the Federal or State WIC Program?

• Yes

• No

Programming Note: If response to Question 30 is “No,” then skip Question 31.

31. For each non-WIC type of support (funding, materials, or “in-kind”) indicate the source of the support provided to your local agency. (Select all that apply for each type of support. For types of support that you do not receive, select “NA.”)

	Source			NA
Type of Support	State Government (other than WIC)	Local Government or Agency	Other Local Sources
Nutrition education funding				
Breastfeeding funding				
Nutrition education staff				
Breastfeeding staff				
Nutrition education materials/supplies				
Breastfeeding education materials/supplies				
Space/facilities				
Other:				

32. What programs or services does your local agency work with to coordinate nutrition education activities (e.g., educational materials, campaigns, classes)? Do not include coordination for outreach or referral purposes. (Select all that apply.)

• Do not coordinate nutrition education with other programs or services

• Breastfeeding coalition or task force

• Child and Adult Care Food Program (CACFP)

• Community Transformation Grant (CTG), REACH, or other CDC program

• Cooperative Extension (Expanded Food and Nutrition Education Program [EFNEP] or other services)

• Food bank, food security, or hunger coalition

• Head Start

• Obesity prevention coalition or task force

• Supplemental Nutrition Assistance Program (SNAP) Education

• Other program or service (describe):

Programming Note: If response to Question 32 is “Do not coordinate nutrition education with other programs or services,” then skip Question 33.

33. How does your local agency coordinate nutrition education with these other programs or services? (Select all that apply.)

• We develop nutrition education materials or campaigns together.

• Another program or service provides nutrition education at WIC sites.

• WIC provides nutrition education at other program or service sites.

• WIC refers participants for other nutrition education programs or services.

• We collaborate on nutrition education goals and action plans.

• We hold joint staff training sessions.

• We meet routinely (e.g., monthly, quarterly) to share information and discuss opportunities to coordinate services.

• Other (describe):

Participant Feedback and Nutrition Education Evaluation

34. How often does your local agency collect feedback from participants about the nutrition education they receive?

• Do not collect participant feedback

• At every WIC visit

• Quarterly

• Twice a year

• Once a year

• Once every other year

• Once every 3 to 5 years

Programming Note: If response to Question 34 is “Do not collect participant feedback,” then skip Question 35.

35. How does your local agency collect feedback from participants about the nutrition education they receive? (Select all that apply.)

• Paper survey completed during WIC visit

• Phone survey conducted by your agency

• Mail survey conducted by your agency

• Phone or mail survey conducted by a company hired by your agency

• Electronic feedback system located at site (e.g., touch-screen survey)

• Focus groups or one-on-one interviews with participants

• Other (describe):

36. If your local agency were to conduct an evaluation of the impact of nutrition education on participant outcomes, which outcome measures would be most important to include? (Select up to five responses.)

• Anemia rates

• Body mass index (BMI) of children

• Breastfeeding rates

• Confidence in skills in preparing healthy meals for children

• Consumption of fruit and vegetables

• Consumption of lower fat milk and dairy products

• Consumption of fruit juice (100% juice)

• Consumption of sugar-sweetened beverages (e.g., soda, sweetened fruit drinks)

• Consumption of whole grains

• Infant feeding practices

• Knowledge about healthy eating

• Physical activity levels

• Readiness for change in nutrition behaviors

• Other (describe):

37. Other than increased funding, what additional resources or information would assist your local agency in providing high-quality nutrition education to participants?

Programming Note: Provide a text field with sufficient space for an open-ended, 8‑line response (800-character response) for Question 37.

About You

Thank you for responding to the questions about nutrition education. The next questions are about you.

38. Which job titles or roles do you have? (Select all that apply.)

• WIC director/coordinator

• Site/clinic supervisor

• Registered dietitian (RD)

• Degreed nutritionist, not RD

• Trained nutrition paraprofessional (e.g., nutrition assistant, nutrition aid, competent paraprofessional authority, diet technician, social services technician)

• Nurse

• Nutrition education coordinator

• Administrative/clerical/support staff

• Lactation consultant/WIC-designated breastfeeding expert

• Breastfeeding coordinator

• Breastfeeding peer counselor

• Other (describe):

Programming Note: If only one option is selected for Question 38, then skip Question 39.

39. Which best describes your primary role in the WIC Program? (Select one response.)

• WIC director/coordinator

• Site/clinic supervisor

• Registered dietitian (RD)

• Degreed nutritionist, not RD

• Trained nutrition paraprofessional (e.g., nutrition assistant, nutrition aid, competent paraprofessional authority, diet technician, social services technician)

• Nurse

• Nutrition education coordinator

• Administrative/clerical/support staff

• Lactation consultant/WIC-designated breastfeeding expert

• Breastfeeding coordinator

• Breastfeeding peer counselor

• Other (describe):

40. What is the highest degree you have completed?

• High school diploma or GED

• Associate’s degree

• Bachelor’s degree

• Graduate degree

41. Which, if any, of the following credentials do you have? (Select all that apply.)

• Registered Dietitian (RD)

• Licensed Dietitian/Nutritionist (LD/LN)

• Dietetic Technician, Registered (DTR)

• Registered Nurse (RN)

• Licensed Practical Nurse (LPN)

• International Board Certified Lactation Consultant (IBCLC)

• Certified Lactation Consultant/Certified Lactation Educator/Certified Lactation Educator & Counselor (CLC/CLE/CLEC)

• Certified Medical Assistant (CMA)

• Other (describe):

• No credentials

42. How many years have you worked for the WIC Program? (Include time at this agency and other WIC experience.)

• Less than 1 year

• 1–3 years

• 4–6 years

• 7–10 years

• 11–20 years

• More than 20 years

WIC Sites Selected for Site Survey

Up to three of your sites were selected to complete a Site Survey as part of the WIC Nutrition Education Study. The name(s) of the site(s) is listed in the table below. For each site, please:

(1) Identify the individual who knows the most about the site’s methods, materials, space, and staffing for nutrition education and provide the requested contact information. Possible job titles for the Site Survey respondent include Local Agency Director, Site/Clinic Supervisor, Site WIC Coordinator, Regional Nutritionist, Regional Nutrition Coordinator, Nutrition Education Coordinator, Competent Professional Authority or Senior Nutritionist.

(2) Provide the information about the site’s caseload/participation, select the type of facility in which the site is located, and enter the ZIP code of the site location.

(3) Notify the individual(s) that you selected them to complete the Site Survey. They will receive an email with instructions for completing the Site Survey. If no email address is provided, a paper survey and prepaid return envelope will be sent to them at the mailing address you enter.

A copy of the Site Survey questions can be viewed by [clicking here].

If you are the most appropriate individual to respond to the questions about the site(s), please enter your name and contact information. If one individual is the most appropriate to answer for two or more sites, select “Same as Site 1” or Same as Site 2” and do not enter the name and contact information for the additional site(s).

Programming Notes: Display names of selected sites in the first row of the table below. If an agency has only one site, leave other columns blank. For “Address,” provide separate fields for Address 1, Address 2, City, State, and ZIP code.

For “Average Monthly Caseload/Participation at Site” allow numeric values from 1 to 99,999.

For “Type of Site,” provide the following selection choices as a list:

• City, county, state or U.S. territory health department (not including government-run hospitals)

• Government facility that does not provide public health or healthcare services (e.g., community center, government service center, courthouse)

• Indian Health Service (IHS) clinic or hospital

• Federally Qualified Health Center (FQHC)

• Nonprofit health center or medical clinic (not including IHS or FQHC)

• Hospital (not including IHS facility)

• Stand-alone WIC site (e.g., leased space in shopping center or other commercial space)

• Nonprofit community services agency facility (e.g., Economic Opportunity Commission, Community Action Agency)

• School or Head Start facility

• Faith-based facility

• Mobile van

• Other

If “Same as Site 1” or “Same as Site 2” is selected for the second or third site, include the same name and contact information entered for the site indicated for the additional site(s). Require the Average Monthly Caseload or Participation at Site, Type of Site and ZIP Code of Site Location to be completed for all sites selected.

If you have any questions about how to complete the table or who should fill out the Site Survey, please contact the Nutrition Education Survey Help Desk at [toll‑free number] or [email].

	[Name of First Site]	[Name of Second Site]	[Name of Third Site]
Site Survey Respondent First Name	______________	Same as Site 1	Same as Site 1 Same as Site 2
		_______________	_______________
Site Survey Respondent Last Name	_______________	_______________	_______________
Site Survey Respondent Job Title	_______________	_______________	_______________
Site Survey Respondent Email Address (if available)	_______________	_______________	_______________
Site Survey Respondent Phone Number	___-___-_______	___-___-_______	___-___-_______
Site Survey Respondent Mailing Address	_______________________________________	_______________________________________________	________________________________________
Average Monthly Caseload or Participation at Site*	______	______	______
Type of Site (Select type that best describes this site’s facility)	__	__	__
ZIP Code of Site Location	_____	_____	_____

*Provide either current caseload at the site or average number of participants served each month at the site.

Thank you for responding to the Local Agency Survey for the
WIC Nutrition Education Study!

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