WIC NE State & Local - Phase II

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

ppendix XXX:
Administrative Data Request for pilot sites

WIC Nutrition Education Study

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 1.4 hours per respondent, 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 assisting with the WIC Nutrition Education Study (NEST). As we mentioned when your site agreed to participate in the pilot study, we would like to obtain information about WIC visits from the records of a subset of participants (30 people) who were enrolled in the pilot study between [MM/DD/YY] and [MM/DD/YY]. The description of the data we are requesting is included below, and we have attached an Excel spreadsheet with the WIC ID numbers and birthdates of the participants who were enrolled in the study.

Our expectation is that it will take sites an average of two respondents, 1.4 hours each, to provide this data (i.e., a total of 2.8 hours). If after reading this request, you think it will take longer than 2.8 hours to respond, or if you have any questions about providing this data, please contact [Name] at [email address] or [xxx-xxx-xxxx]. She can assist you with the request and answer any questions you may have.

We request that you provide a file or insert the requested data on the attached spreadsheet, whichever is easiest for you. Please submit the data to RTI International, the contractor conducting the study for USDA, Food and Nutrition Service, via one of the options described in the Data File Submission section of this request by [MM/DD/YY].

Description of Data Requested

For the sample of participants enrolled in the pilot study, we are requesting the date of each WIC visit between MM/DD/YY and MM/DD/YY. If the information is available, we would also like to know if the participant (or their parent/guardian/caretaker or proxy) received nutrition education at the visit and whether the participant was “high risk.” By high risk we mean the participant was identified as high risk or the participant had nutrition risks requiring special attention at any time during the study period. The WIC ID number and birthdate are for each participant enrolled in the study including pregnant, postpartum and breastfeeding women, infants and children. Following are the descriptions of the data requested.

1. WIC Visit Date: For each visit during the specified time period, enter the date using MM/DD/YY format.

2. Received Nutrition Education (if available): For each visit date, enter “Y” if the participant/parent/guardian received nutrition education and “N” if she did not. Leave blank if the information is not available.

3. High-Risk Status (if available): For each participant, enter “1” if the recipient of WIC benefits is considered high risk and a “0” if the recipient is not high risk. Please contact [Name] at [email address] or [xxx-xxx-xxxx] if this information is not available to determine if a proxy for this information is available.

An example of the spreadsheet format is included below.

WIC ID #	Birth Date	(1) WIC Visit Dates (MM/DD/YY)	(2) Received Nutrition Education (Y or N)	(3) High-Risk Status (1 = high risk, 0 = not high risk)
2233445566	04/02/2012	07/12/15	Y	1
2233445566	04/02/2012	10/13/15	N	1
2233445566	04/02/2012	1/20/15	Y	1
2233445566	04/02/2012	4/16/15	Y	1

Data File Submission

The preferred file format is Excel (appending the requested information to the file provided) but other formats are acceptable. If using another format, please provide a description of the file contents.

There are two recommended options for submitting the data to RTI.

1. Upload it to a secured FTP site by [include instructions for submitting via FTP] or

2. Encrypt the data and send it via email to [Name] at [email address].

If neither of these two options for data submission is feasible or if you have any questions about submitting the data, please contact [Name] at [email address] or [xxx-xxx-xxxx].

Consent Forms

All participants who are in the pilot study have signed consent forms agreeing to have data from their or their child’s WIC records shared with RTI. A copy of the signed consent form for each participant was provided to the WIC site at the time the participant was enrolled in the study.

If you require copies of the consent forms or a data use agreement in order to provide the requested data or if you have any questions about this request, please contact [Name] at [email address] or [xxx-xxx-xxxx].

Thank you for your assistance with this request. We appreciate your assistance with the WIC Nutrition Education Study (NEST).

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