WIC NE State & Local - Phase I

APPENDIX C.3:
Site Paper Survey Version 1—English

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

WIC Nutrition Education Study

Site Survey (Version 1)

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 Site 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 sites provide nutrition education to participants. This site was randomly selected as part of a group of about 2,000 sites that represent all WIC sites in the nation. Your responses to the survey will be combined with responses from the other sites to develop a comprehensive picture of the methods, staffing, resources, and space 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/programs, 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 box  for you to check response(s). A few questions require that you enter numbers or text responses. Please use blue or black ink to complete the survey. The survey will take about 45 minutes to complete. We recommend that you review the questions before beginning the survey so that you can obtain any information needed to respond or ask other staff at the site to assist with answering some of the questions.

Questions 10 through 16 ask about the characteristics of staff members who provide nutrition education (e.g., education, credentials, etc.). You can use the enclosed optional form to help answer these questions. You do not need to return the form, only the completed survey.

Nutrition Education Survey Help Desk

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

[Toll-free phone number]

[Email address]

Nutrition Education Contacts and Methods

For all questions, nutrition education includes breastfeeding education.

1. How many days per month does the site provide WIC nutrition education services? (Count days when any form of nutrition education is provided. If it varies from month to month, enter the number of days WIC nutrition education services were provided last month.)

Number of days: _____

2. Are participants at the site classified into nutrition risk levels (e.g., high risk, not high risk)?

• Yes

• No

3. What, if any, modifications to nutrition education does the site 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. (Check 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): _______________________________________

1. In the first column, enter the number of nutrition education contacts the site offers (i.e., makes available) during a certification period for each participant category and time period. While the number of contacts varies based on individual needs, enter the number that is offered to the majority of participants in the category. (Count all contacts beginning with the certification visit; for example, if prenatal women who enroll in the 1^st trimester are offered nutrition education at their initial visit and two more contacts during their prenatal certification period, enter “3.” Enter NA for any category/time period that is not applicable at the site.)

In the second column, enter the estimated percentage of participants who receive that number of nutrition education contacts during their certification period. (Please estimate based on your experience. You do not need to run a report or review participant records to answer this question.)

Participant Category and Time Periods	Number of Nutrition Education Contacts Site Offers during Certification Period	Estimated Percentage of Participants who Receive this Number of Contacts
Participants who are NOT 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
Child, 12-month certification
Participants who are high risk and/or have nutritional risks requiring special attention
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

5. During what types of visits does the site provide nutrition education contacts? (Check 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, breastfeeding follow-up, low risk follow-up)

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

• Other visits (describe):

6. What methods are used to provide nutrition education? (Check all methods that are used for each type of visit. Check NA if the site does not provide this type of visit.)

Method	Enrollment Certification	Recertification	Mid-certification	Secondary Education	High-Risk	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., web-based nutrition education modules)						
Other nutrition education activities (e.g., monthly topic, worksheets, videos, self-study modules)						
Type of visit not provided (NA)						

7. On average, how much time do staff members who provide nutrition education at the site spend providing nutrition education during each of the following types of WIC visits? Do not include time spent on eligibility (e.g., income and residency) or assessment (e.g., weighing/measuring, blood work, reviewing nutrition questionnaires). (Check NA if the site does not provide this 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									

Nutrition Education Staff

The next questions ask about the staff members at the site who provide nutrition education. If the number of these staff varies on different days, respond about staffing for a “typical” day or use the most common/frequent staffing pattern for the site. Count staff who provide nutrition education using any method. Do not include translators or interpreters who assist nutrition educators.

8. Which best describes the staff members who provide nutrition education at the site? (Check one response.)

• All of them work only for WIC.

• All of them work for WIC and for other programs or services (e.g., immunizations, family planning) offered at the site.

• Some of them work only for WIC and some work for WIC and other programs or services offered at the site.

9. For each job classification/type of staff, enter the number of staff who currently provide nutrition education at the site who work full time and the number who work part time. (If a staff member works 32 or more hours/week on WIC, count them in the Full-Time Staff column and if less than 32 hours/week on WIC, count them in the Part-Time Staff column appropriate for the number of hours they work per week. If a staff member performs more than one role, count them only once in the job classification/type for their primary role.)

Job Classification/Type of Staff	Number of Full-Time Staff (work on WIC activities 32 or more hours per week)	Number of Part-Time Staff (work on WIC activities 21–31 hours per week)	Number of Part-Time Staff (work on WIC activities 20 or fewer hours per week)
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:_______________
Total

If you completed the optional form you can refer to this form to answer Questions 10 through 16 on the characteristics of staff members who provide nutrition education.

10. How many years have staff members who provide nutrition education at the site worked for WIC? (Count both full-time and part-time staff and count each staff member only one time for the total number of years they have worked for WIC. Include time worked at this site or local agency/program and time at other WIC sites or local agencies.)

    Number of Years Worked at WIC	Number of Staff who Provide Nutrition Education
    Less than 1 Year
    1–2 Years
    3–6 Years
    7–10 Years
    11–20 Years
    More Than 20 Years
    Total

11. What is the educational level of individual staff members who provide nutrition education at the site? (Count both full-time and part-time staff and count each staff member only one time for the highest degree they have received.)

Education Level (Highest Degree Received)	Number of Staff who Provide Nutrition Education
High school diploma or GED
Associate’s degree
Bachelor’s degree
Graduate degree
Unknown
Total

12. How many of the staff members who provide nutrition education at the site have one or more of the credentials* listed below? (If a staff member has more than one credential, count them for each credential they have; for example, if a staff member is both an RD and a LD/LN, count them in each credential group. If no staff members have any of these credentials, check “None of these credentials” box).

Credentials	Number of Staff who Provide Nutrition Education
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)
None of these credentials	

*A credential is a certification from a professional association or training program.

13. What is the ethnicity of staff members who provide nutrition education at the site? (If you do not know the ethnicity of a staff member, count them in the “Unknown” category.)

Hispanic or Latino Ethnicity	Number of Staff who Provide Nutrition Education
Hispanic or Latino
Not Hispanic or Latino
Unknown
Total

14. What is the race of staff members who provide nutrition education at the site? (Staff members may be included in more than one category. If you do not know the race of a staff member, count them in the “Unknown” category.)

    Race	Number of Staff who Provide Nutrition Education
    American Indian or Alaska Native
    Asian
    Black or African American
    Native Hawaiian or other Pacific Islander
    White
    Unknown

15. How many staff members provide nutrition education in a language other than English? (Do not include interpreters and translators.)

Number of staff: _______  IF 0, GO TO QUESTION 17.

16. Other than English, what languages are spoken by staff who provide nutrition education at the site? (Check 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):

Site and Participant Characteristics

17. In addition to WIC, which of the following services are available at or near the site? (Check all that apply.)

• Children’s health care

• Dental services

• Environmental health/screening

• Family planning services

• Lead screening

• Maternal/prenatal health care

• Parenting support

• Prevention and screening services (e.g., vision, early and periodic screening, immunizations)

• Sexually transmitted disease services

• Smoking cessation

• There are no other services available at this site.

• Other (describe)

18. What settings at the site are used for one-on-one counseling? (Check all that apply.)

• Private room (full walls and door, e.g., office, exam/lab room)

• Modular office/cubicle (with full or partial walls)

• Area with movable partitions separating it from other space

• Open area with no partitions and staff at desks that are arranged for privacy

• Open area with no partitions and staff at tables (e.g., waiting room, community center room)

• Other (describe):

19. What settings at the site are used for group education sessions? (Check all that apply.)

• Designated room or space used predominately for group education

• Multi-purpose room used for group education and other meetings, but not a waiting room (e.g., conference room, auditorium)

• General open area (e.g., waiting room, open room where all WIC activities take place)

• Private room used for both one-on-one counseling and group education

• Other (describe):

• This site does not provide group education sessions.

20. Which, if any, of these rooms/areas are available at or near the site? (Check all that apply.)

• Designated room/area where breastfeeding education is provided

• Kitchen/area for cooking classes or recipe preparation demonstrations

• Room/area for nutrition education activities with children

• Room/area for providing WIC orientation to families

• Room/area for viewing nutrition education or breastfeeding videos

• None of the above

21. Which, if any, of these equipment items or materials does the site have available for providing nutrition education? (Check all that apply.)

• Bulletin boards for nutrition education information

• Computer, kiosk, or tablet computer for nutrition education

• Display tables with nutrition information

• DVD player and TV for showing nutrition education information

• Equipment for teaching cooking classes (e.g., stove, refrigerator)

• Equipment for simple food tasting (e.g., blender, crock pot)

• Nutrition education curricula or materials targeted to children (e.g., Sesame Workshop, kids’ camp)

• Nutrition newsletters

• Rack/table/stand with written nutrition education materials for participants to select

• Other (describe):

• None of the above

22. About what percentage of participants served at the site speak a language other than English as their primary language? (Please estimate if this information is not readily available. You do not need to run a report or review participant records to answer this question.)

• None  GO TO QUESTION 24

• 1–5%

• 6–10%

• 11–30%

• 31–50%

• 51–70%

• 71–90%

• 91-100%

23. Other than English, what languages are spoken by participants served at the site? (Check 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):

Questions about You

24. Did you complete the Local Agency Survey for the local agency/program that oversees this site?

• Yes  GO TO QUESTION 30

• No

25. Which job titles or roles do you have? (Check 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):

If you chose only one response for Question 25, GO TO QUESTION 27.

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

• 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 (describe):

27. What is the highest degree you have completed?

• High school diploma or GED

• Associate’s degree

• Bachelor’s degree

• Graduate degree

28. Which, if any, of the following credentials do you have? (Check 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

29. How many years have you worked for the WIC Program? (Include time at this site or local 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

30. As part of your job, do you design and/or oversee nutrition education at the site?

• Yes

• No

31. As part of your job, about what percentage of your time each month is spent providing nutrition education to WIC participants?

• Less than 25%

• 25–49%

• 50–74%

• 75–100%

32. Please use the space below to share a brief description of any special nutrition education activities or approaches used at the site.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Thank you for completing the Site Survey for the WIC Nutrition Education Study!

Nutrition Education Staff Summary

Instructions: This is an optional form you can use to gather information about the staff at the site that provide nutrition education. Listed below each column heading is the corresponding survey question. An example of how to complete the form is shown in the first line.

First Name and Last Initial of Staff at the Site who Provide Nutrition Education	Number of Years Worked at WIC Question 10 (Select one)						Education Level – Highest Degree Received Question11 (Select one)					Credentials Question 12 (Select all that apply)									Ethnicity Question 13 (Select one)			Race Question14 (Select all that apply)						Languages Spoken Other than English Question 16 (Select all that apply)
	Less than 1 year	1 – 2 years	3 – 6 years	7 – 10 years	11 – 20 years	More than 20 years	High school or GED	Associate’s Degree	Bachelor’s Degree	Graduate Degree	Unknown	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)	None of these credentials	Hispanic or Latino	Not Hispanic or Latino	Unknown	American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White	Unknown	Spanish	All other languages (specify)
Employee A.		X					X					X					X				X							X		X
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