WIC NE Individuals/Household - Phase II

Appendix AA.1. Participant Survey Electronic Screener—English

A

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

PPENDIX AA.1:
PARTICIPANT SURVEY ELECTRONIC SCREENER—ENGLISH

1. Screening Questionnaire for Phase II Participant Surveys

WIC Nutrition Education Study

Screening Questionnaire for Participant Surveys

1. [If NECESSARY] Do you prefer to talk and read in English or Spanish?

   • English

   • Spanish [USE SPANISH SCREENER]

   • Does not read or understand English or Spanish  [Go to terminate script-ineligible.]

2. What is your age? ____________

   • Less than 18 years old  [Go to terminate script-ineligible.]

   • 18 or older

3. Which of the following describes you? [READ LIST. CHECK ALL THAT APPLY]

   • You are pregnant on WIC or signing up today [A]

   • You are a mother with a baby less than 6 months old on WIC or signing up today [B] [INTERVIEWER NOTE: MOTHER, BABY, OR BOTH COULD BE ON WIC.]

   • You are a mother or caregiver of a child who is less than 4 years old on WIC or signing up today [C]

   • NONE OF THE ABOVE  [Go to terminate script-ineligible.]

If two or more of the first three responses are checked, the electronic screener will randomly select a category and go to the appropriate category to complete the screening and enrollment process.

1. Pregnant

4. When is your due date?

Month:__________ Day:__________

Eligible for Pregnant Survey. Go to QUESTION 11.

2. Postpartum (Mother with baby less than 6 months old)

5a. Is your baby a boy or girl? [If Multiple Births, ask For Gender of The Child Born First.]

5. Boy

6. Girl

5b. When was your baby born?

Month: __________ Day: __________

Eligible for Postpartum Survey Go to QUESTION 11

3. Child (Mother or caregiver with child between ages of 6 months and up to 4 years old)

6. How many children between the ages of 6 months and 4 years are you signing up to get WIC benefits or already have WIC benefits?

_____________ children

[If > one child, [Go to QUESTION 7.]

[If one child]

6a. What is the child’s first name? _______________________________

6b. CONFIRM GENDER.

7. Boy

8. Girl

[Go to Question 8.]

7. For each child on WIC or signing up for WIC, please tell me whether the child is a boy or girl and the month and year the child was born.*

Child	Gender		Month of Birth	Year of Birth
1	Boy	Girl
2	Boy	Girl
3	Boy	Girl
4	Boy	Girl
5	Boy	Girl
6	Boy	Girl

*The electronic screener will select the child with the month of birth closest to today to be the target child for the survey if more than one child on WIC. If there are more than two children with the same month of birth, then the electronic screener will select the child listed first. Mothers of children younger than 6 months should complete the Postpartum Survey. Children who have had their fourth birthday are not eligible for the study.

Your [insert daughter/son] born in [insert month of birth and year of birth] is the one we will ask questions about in the study. What is this child’s first name?

Child’s FIRST Name: ____________________________

8. What is your relationship to this child?

9. Mother [Go to Question 11.]

10. Aunt

11. Grandmother

12. Father

13. Other family member (specify relationship to child) __________________

14. Nonfamily member/friend

9. [If not mother] Are you knowledgeable about what this child eats on a daily basis?

• NO  [Go to terminate script-ineligible.]

• YES

10. [If not mother] During the next 12 months, will you be the person coming to WIC for this child’s WIC visits instead of the child’s mother?

15. NO  [Go to terminate script-ineligible.]

16. YES

Eligible for Child Survey. Write Child’s First Name on Contact Card and Go to
QUESTION 11

11. Thank you for your answers. Would you like to take part in our study? You will get $50 if you fill out all three surveys over the next 12 months.

17. NO  [Ask if she has any questions about the study to see if she will reconsider.] [Go to terminate script-refusal.]

18. YES

12. Great! Please read this sheet that explains what the study will involve. [If participant prefers, you can read it to them.]

[After reading sheet] Do you have any questions? Please fill out this contact card if you want to take part in this study. [ENTER ID NUMBER FROM CONTACT CARD. DOUBLE ENTER FOR VERIFICATION.]

ID No. __________________

ID No. __________________

13. Please check one of the following:

19. Participant read informed consent sheet and did not agree to participate [Go to terminate script-refusal.]

20. Participant read informed consent sheet and agreed to participate

14. If participant agreed to participate, please check the following:

21. Participant completed contact card

22. Participant refused to complete contact card [Go to terminate script-refusal.]

15A. [Ask if pregnant/postpartum women.] As described in the sheet I gave you, we plan to get information from WIC on when you visit the clinic for nutrition education. To be able to do this, I need your birthdate.

What month were you born in? ________________ (Drop down box)

What date were you born on? _________________ (Drop down box)

What year were you born in? __________________ (Drop down box)

[REPEAT BACK INFORMATION TO VERIFY FOR ACCURACY.]

15B. [Ask if child recipient.] As described in the sheet I gave you, we plan to get information from WIC on when you visit the clinic for nutrition education. To be able to do this, I need the birthdate for [Insert target child’s first name.]

What month was he/she born in? ________________ (Drop down box)

What date was he/she born on? _________________ (Drop down box)

What year was he/she born in? __________________ (Drop down box)

[REPEAT BACK INFORMATION TO VERIFY FOR ACCURACY.]

16. [Record gender of person screened]

23. Female

24. Male

17. Give participant appropriate version of the survey with the corresponding ID number and ask them to complete Section 1 before their WIC appointment. Instruct participant to give back the survey when called for their WIC appointment and to return to Field representative to complete survey after their WIC appointment.

[Terminate Script – Ineligible.] Thank you for your time. I’m sorry, but you do not meet the criteria to take part in our study. Have a good day.

[Terminate Script – Refusal.] Thank you for your time. Have a good day.

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