WIC NE Individuals/Household - Phase II

Appendix CC.1:
PREGNANT WOMEN BASELINE PAPI SURVEY—ENGLISH

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

Baseline Survey for Pregnant Women

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 20 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.

Please fill out and return the survey to the research study staff. Your identity and your answers on the survey will be kept private. We will not share your name and contact information with anyone without your consent. You may skip any questions you do not want to answer. We want to know about you. There are no right or wrong answers.

Mark only one x for each question unless it says to mark more than one answer. To change your answer, completely fill the box of the incorrectly marked answer ■. Then mark an x in the correct box.

If you have any questions about this study, please send an e‑mail to [email protected]
or call toll-free at 1-866-800-####.

1. Different people like different foods. How much do you like …?

	Never Tried	Don’t Like at All	Like a Little	Like a Lot
a. Vegetables				
b. Fruit				
c. Low-fat (1%) or fat-free/skim milk				
d. Whole grains such as whole grain bread, whole wheat or corn tortillas, or brown rice				

The next questions are about the different kinds of foods you ate or drank during the past month, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, and anyplace else.

2. In the past 30 days, how often did you eat hot or cold cereals?

• Never  GO TO Question 4

• Once last month

• 2–3 times last month

• Once a week

• Twice a week

• 3–4 times per week

• 5–6 times per week

• Once a day

• More than once a day

3a. In the past 30 days, what kind of cereal did you usually eat? (Print the name of the cereal.)

3b. If there was another kind of cereal that you usually ate in the past 30 days, what kind was it? (Print the name of the cereal, or if none, leave blank.)

3. In the past 30 days, how often did you have any milk (either to drink or on cereal)? Include regular milk, chocolate or flavored milk, lactose-free milk, and buttermilk. Do not include soy milk, almond milk, rice milk, etc. or small amounts of milk added to coffee or tea.

• Never  GO TO Question 5

• Once last month

• 2–3 times last month

• Once a week

• Twice a week

• 3–4 times per week

• 5–6 times per week

• Once a day

• More than once a day

4. In the past 30 days, what kind of milk did you usually drink? (Mark one or more.)

• Whole or vitamin D milk

• 2% or reduced-fat milk

• 1% or low-fat milk

• Fat-free or nonfat/skim milk

• Soy milk

• Chocolate or flavored milk

• Other:__________________________

5. In the past 30 days, how often did you drink …?

   	Never	Once Last Month	2–3 Times Last Month	Once a Week	Twice a Week	3–4 Times per Week	5–6 Times per Week	Once a Day	More than Once a Day
   a. Regular soda or pop that contains sugar (Do not include diet soda)									
   b. 100% pure fruit juices with no added sugar, such as orange, mango, apple, grape, and pineapple juices									
   c. Coffee or tea that had sugar or honey added to it such as coffee and tea you sweetened yourself and presweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino (Do not include coffee or diet tea with artificial sweeteners such as Equal, Sweet’N Low, or Splenda)									
   d. Sweetened fruit drinks, sports drinks, or energy drinks, such as Kool-Aid, lemonade, HiC, cranberry drink, Gatorade, Red Bull, Vitamin Water, or fruit juices you made at home and added sugar (Do not include diet drinks with artificial sweeteners, such as Equal, Sweet’N Low, or Splenda)									

6. In the past 30 days, how often did you eat …?

	Never	Once Last Month	2–3 Times Last Month	Once a Week	Twice a Week	3–4 Times per Week	5–6 Times per Week	Once a Day	More than Once a Day
a. Fruit, including fresh, frozen, dried, or canned fruit (Do not include juices)									
b. Green leafy or lettuce salad, with or without other vegetables									
c. Any kind of fried potatoes, including French fries, home fries, or hash brown potatoes									
d. Any other kind of potatoes, such as baked, boiled, mashed potatoes; sweet potatoes; or potato salad									
e. Refried beans, baked beans, beans in soup, pork and beans, or any other type of cooked dried beans (Do not include green beans)									
f. Brown rice or other cooked whole grains, such as bulgur, cracked wheat, or millet (Do not include white rice)									
g. Other vegetables, including fresh, frozen, dried, or canned vegetables (Do not include green salads, potatoes, or cooked dried beans)									
h. Mexican-type salsa made with tomatoes									
i. Pizza, including frozen pizza, take-out pizza, pizza in restaurants, and homemade pizza									
j. Tomato sauce served with spaghetti or noodles or mixed into other foods such as lasagna (Do not include tomato sauce on pizza)									
k. Any kind of cheese, including cheese as a snack; cheese on burgers and sandwiches; and cheese in foods such as lasagna, quesadillas, or casseroles (Do not include cheese on pizza)									
l. Corn or whole wheat tortillas (Do not include white flour tortillas)									

6. In the past 30 days, how often did you eat …? (continued)

	Never	Once Last Month	2–3 Times Last Month	Once a Week	Twice a Week	3–4 Times per Week	5–6 Times per Week	Once a Day	More than Once a Day
m. Whole grain bread, including whole wheat, rye, oatmeal, and pumpernickel toast and rolls and in sandwiches (Do not include white bread)									
n. Chocolate or any other types of candy (Do not include sugar-free candy)									
o. Doughnuts, sweet rolls, Danish, muffins, pan dulce, or Pop-Tarts (Do not include sugar-free kinds)									
p. Cookies, cake, pie, or brownies (Do not include sugar-free kinds)									
q. Ice cream or other frozen desserts (Do not include sugar-free kinds)									

7. Everyone is different and eats different foods. At this time, are you doing the following things? (Mark one box for each row.)

   	NOT thinking about doing it	Thinking about doing it	Planning on doing it in next month	Have been doing it for LESS than 6 months	Have been doing it for 6 months or LONGER
   a. Eat vegetables at dinner every day					
   b. Eat fruit for a snack instead of cookies or chips every day					
   c. Drink low-fat (1%) or fat-free/skim milk instead of whole milk or 2% (reduced fat) milk every day					
   d. Almost always eat whole grain bread instead of white bread					
   e. Almost always eat brown rice instead of white rice					
   f. Almost always eat whole wheat or corn tortillas instead of white flour tortillas					
   g. Drink 100% juice NO MORE than once a day					
   h. Drink regular soda or pop, sweetened fruit drinks, sports drinks or energy drinks NO MORE than once a month					

8. How sure are you that you can…?

   	Not Sure	A Little Sure	Very Sure
   a. Only formula feed my baby (not breastfeed at all)			
   b. Breastfeed my baby or at least try			
   c. Breastfeed without using any formula or other milk when my baby is 30 days old			
   d. Breastfeed without using any formula or other milk when my baby is 6 months old			

9. How sure are you that you can …?

	Not Sure	A Little Sure	Very Sure
a. Eat vegetables at dinner every day			
b. Eat fruit for a snack instead of cookies or chips every day			
c. Drink low-fat (1%) or fat-free/skim milk instead of whole milk or 2% (reduced fat) milk every day			
d. Eat whole grain bread instead of white bread			
e. Eat brown rice instead of white rice			
f. Eat whole wheat or corn tortillas instead of white flour tortillas			
g. Drink 100% juice NO MORE than once a day			
h. Drink regular soda or pop, sweetened fruit drinks, sports drinks or energy drinks NO MORE than once a month			

Thank you for answering these questions!

Please give your survey to the research study staff.

After your WIC appointment, please return to answer some additional questions.

Please complete Section 2 of the survey now.

10. How much do you agree or disagree …?

    	Disagree a Lot	Disagree a Little	Agree a Little	Agree a Lot
    a. It is easy to buy fresh fruit and vegetables where I live				
    b. It is expensive to buy fresh fruit and vegetables where I live				
    c. There is a large selection of fresh fruit and vegetables where I live				
    d. The fresh fruit and vegetables where I live are of high quality				

11. Was this true for your household in the past 12 months?

    	Never True	Sometimes True	Often True
    a. We worried whether our food would run out before we got money to buy more			
    b. The food that we bought just didn’t last, and we didn’t have money to get more			

12. How often do these things happen?

    	Rarely or Never	Some Days	Most Days	Almost Every Day	Every Day
    a. I eat a meal while watching TV					
    b. I cook a homemade dinner at home					

13. Have you breastfed any of your other children for 1 month or more?

• No, this is my first pregnancy

• Yes

• No

14. All people do things differently. Think about what you do in a usual week or day. How many times do you do the following things? (Mark one box for each question.)

    	0	1	2	3	4	5	6	7	8 or More
    a. I eat breakfast ___ times a week								
    b. I eat out ___ times a week									
    c. I eat fast food ___ times a week									
    d. I watch TV or DVDs ___ hours a day									

15. In the past 7 days, on how many days did you do moderate or vigorous physical activities like walking, jogging, dancing, or bicycling? Think only about physical activities that you did for at least 10 minutes at a time. (Circle one number.)

0	1	2	3	4	5	6	7
If you circled 0  GO TO Question 17

16. On the days that you did more than 10 minutes of moderate or vigorous physical activities, how many minutes in a day did you usually spend doing these physical activities?

• 10–20 minutes

• 21–30 minutes

• 31–40 minutes

• 41–50 minutes

• 51–60 minutes

• More than 60 minutes

17. In the past 30 days, how often did your family or friends do the following?

    	Almost Never	Once in a While	Sometimes	Often	Almost Always
    a. Encourage you to eat healthy foods					
    b. Complain about eating healthy foods					
    c. Encourage you to do physical activity					
    d. Do physical activity with you					

18. In the past 30 days, how often did you …?

	Almost Never	Once in a While	Sometimes	Often	Almost Always
a. Plan meals ahead of time					
b. Use Nutrition Facts on food labels to choose foods					

19. Add up all the time you or your children have ever been on WIC. Has it been …?

• Less than 30 days

• 1 month to a year

• 1–2 years

• 3–4 years

• 5 or more years

20. In the past 6 months, how many times did you visit a WIC office and get information on health or healthy eating? Include the day you signed up for this study. Do not include visits for other reasons such as picking up a food instrument or voucher or taking a friend to her appointment. (Mark “Once” if the day you signed up for this study was your first visit to a WIC office.)

• None

• Once

• 2 times

• 3 times

• 4 times

• 5 times

• 6 or more times

21. In the past 6 months, during WIC visit(s) how many times did you …? Include your most recent visit.

    	None	1	2	3	4	5	6 or More
    a. Talk one-on-one with a WIC staff person about health or healthy eating							
    b. Attend a group session about health or healthy eating							
    c. Watch a video/DVD about health or healthy eating							
    d. Use the WIC Web site about health or healthy eating							

22. In the past 6 months, in between WIC visits, what did you get from WIC with information that told you about health or healthy eating? Do not include things you got during your WIC visit. (Mark all that apply.)

• Personal phone call

• Text message

• Email message

• Online education that I could log into from home or someplace else

• Invitation or link to Facebook, Twitter, or other social media site

• Brochure or handout in the mail

• None of the above

The next questions are about your most recent visit to WIC in which you got information on health or healthy eating.

23. What did you do at your most recent WIC visit? (Mark all that apply.)

• Talked one-on-one with a WIC staff person about health or healthy eating

• Spent time in a group session on health or healthy eating

• Used a WIC Web site on health or healthy eating

• Used a WIC video/DVD on health or healthy eating

• None of the above

24. For your most recent WIC visit, how much do you agree or disagree with each statement …?

    	Disagree a Lot	Disagree a Little	Agree a Little	Agree a Lot
    a. I learned good reasons to eat healthy				
    b. I learned good ways to eat healthy				
    c. I learned good reasons to breastfeed				
    d. I learned good ways to breastfeed				

25. Some people say that some WIC visits are more helpful than others. Which best describes the information you received at your most recent WIC visit? (Mark one box only.)

• The information was helpful because it was new to me.

• The information was helpful. I knew the information, but it was good to hear it again.

• The information was not that helpful because I already knew it.

• The information was not that helpful because it did not apply to me.

26. Which best describes your most recent WIC visit? (Mark one box only.)

• I did not have any children with me

• I had a child with me so it made it hard to listen to the WIC information

• I had a child with me but it was easy to listen to the WIC information

27. At your most recent WIC visit, did the WIC staff show you any of the following or use any of these with you while they talked about health or healthy eating? (Mark all that apply.)

• Brochure, handout, or paper with information

• Bulletin board or poster

• Video/DVD

• Tasting or cooking demonstration

• Activity or game

• Other items that you could pass around like measuring cups, food containers, etc.

• None of the above

• Other: ________________________________________________

28. When you enroll in WIC and then 6 to 12 months later, WIC asks you to bring proof of address or income to make sure you can be on WIC. Did you bring proof to your most recent WIC visit?

• Yes

• No

29. At your most recent WIC visit, how long did you talk one-on-one with a WIC staff person about health or healthy eating?

• I did not talk one-on-one about health or healthy eating  GO TO Question 35

• Less than 5 minutes

• 5–15 minutes

• 16–30 minutes

• More than 30 minutes

Answer Questions 30 to 34 only if you had one-on-one time with WIC staff at your most recent WIC visit. (If you did not have one-on-one time, go to Question 35.)

30. Which best describes your most recent one-on-one time with a WIC staff person? (Mark the one that happened most.)

• The WIC staff person chose what we talked about

• I chose what we talked about

• The WIC staff person and I together chose what we talked about

31. A health goal means trying to become healthier by changing something you do. Which best describes your most recent one-on-one time with a WIC staff person? (Mark the one that happened most.)

• S/he worked with me to set health goals for me or my child

• S/he talked about health goals, but I did not set any

• S/he did not talk about setting health goals

32. For each statement, how much do you agree or disagree about your most recent one-on-one time with a WIC staff person?

	Disagree a Lot	Disagree a Little	Agree a Little	Agree a Lot
a. The WIC staff person talked most of the time				
b. The WIC staff person listened to me and understood my concerns				
c. The WIC staff person followed up on issues or questions from my last one-on-one visit				

Did you talk about this topic in your one-on-one time? (Mark one box for each topic below.)				Have you made or do you think you will make a change to your eating or activities since discussing this topic? (Mark one box for each topic discussed.)
	We talked about this	We did NOT talk about this		I am NOT thinking about doing it	I am thinking about doing it	I am planning on doing it	I am already doing it
a. Eating more fruit and vegetables							
b. Eating more whole grains like whole grain bread, whole wheat or corn tortillas, or brown rice							
c. Drinking lower fat milk (1% or fat-free/skim milk)							
d. Getting more physical activity							
e. Shopping for and preparing healthier foods							
f. Drinking water instead of soda and sugary drinks							
g. Breastfeeding							

35. At your most recent WIC visit, how long did you spend in a group session talking about health or healthy eating?

• I was not in a group session  GO TO Question 41

• Less than 5 minutes

• 5–15 minutes

• 16–30 minutes

• More than 30 minutes

Answer Questions 36 to 40 only if you spent time in a group session at your most recent WIC visit. (If you were not in a group session, go to Question 41.)

36. Which best describes your most recent WIC group session? (Mark the one that happened most.)

• S/he mostly talked and would stop to ask if we had questions

• We watched a video/DVD and at the end s/he asked if we had questions

• S/he shared information, and we had a discussion. S/he asked me and the other people in the group about our thoughts and opinions.

37. A health goal means trying to become healthier by changing something you do. Which best describes your most recent group session with a WIC staff person? (Mark the one that happened most.)

• S/he worked with me to set health goals for me or my child

• S/he talked about health goals, but I didn’t set any

• S/he did not talk about setting health goals

38. For each statement, how much do you agree or disagree about your most recent WIC group session?

	Disagree a Lot	Disagree a Little	Agree a Little	Agree a Lot
a. The WIC staff person listened to the group and understood our concerns				
b. I had a chance to bring up topics that were important to me				

Did you talk about this topic in your group session? (Mark one box for each topic below.)				Have you made or do you think you will make a change to your eating or activities since discussing this topic? (Mark one box for each topic discussed.)
	We talked about this	We did NOT talk about this		I am NOT thinking about doing it	I am thinking about doing it	I am planning on doing it	I am already doing it
a. Eating more fruit and vegetables							
b. Eating more whole grains like whole grain bread, whole wheat or corn tortillas, or brown rice							
c. Drinking lower fat milk (1% or fat-free/skim milk)							
d. Getting more physical activity							
e. Shopping for and preparing healthier foods							
f. Drinking water instead of soda and sugary drinks							
g. Breastfeeding							

41. Which describes how you used a WIC Web site on health or healthy eating in the past 6 months? (Mark all that apply.)

• Used a WIC Web site on health or healthy eating in the WIC office by myself

• Used a WIC Web site on health or healthy eating instead of going to a WIC appointment

• Used a WIC Web site on health or healthy eating before or after going to a WIC appointment

• Have not used a WIC Web site on health or healthy eating in the past 6 months  GO TO Question 46

Answer Questions 42 to 45 only if you used a WIC Web site on health or healthy eating in the past 6 months. (If you did not use a WIC Web site, go to Question 46.)

42. How long did you spend using the WIC Web site? Include time in and outside of WIC office.

• Less than 5 minutes

• 5–15 minutes

• 15–30 minutes

• More than 30 minutes

43. Which best describes how the topic for the WIC Web site was chosen? (Mark one.)

• There was a list of topics, and I chose one of them myself

• There was a list of topics, and a WIC staff person helped me choose one

• There was only one topic available

• Other: ____________________________

Did you read or view this topic on the WIC Web site? (Mark one box for each topic below.)				Have you made or do you think you will make a change to your eating or activities since reading/viewing this topic? (Mark one box for each topic read/viewed.)
	I read/ viewed this	I did NOT read/ view this		I am NOT thinking about doing it	I am thinking about doing it	I am planning on doing it	I am already doing it
a. Eating more fruit and vegetables							
b. Eating more whole grains like whole grain bread, whole wheat or corn tortillas, or brown rice							
c. Drinking lower fat milk (1% or fat-free/skim milk)							
d. Getting more physical activity							
e. Shopping for and preparing healthier foods							
f. Drinking water instead of soda and sugary drinks							
g. Breastfeeding							

46. Which describes how you used a WIC video/DVD on health or healthy eating in the past 6 months? (Mark all that apply.)

• Used a WIC video/DVD on health or healthy eating in the WIC office by myself

• Used a WIC video/DVD on health or healthy eating in the WIC office in a group

• Used a WIC video/DVD on health or healthy eating instead of going to a WIC appointment

• Used a WIC video/DVD on health or healthy eating before or after going to a WIC appointment

• Have not used a WIC video/DVD on health or healthy eating in the past 6 months

47. Which best describes your current status? Are you …? (Mark the best answer.)

• Married

• Widowed

• Divorced

• Separated

• Single or never married

• Living with partner

48. Are you Hispanic or Latino? (Mark one.)

• Hispanic or Latino

• Not Hispanic or Latino

49. What is your race? (Mark one or more.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

• Other; Specify:________________________________

50. What is the highest year or grade you finished in school? (Mark one.)

• Less than 1 year of school

• Elementary (grades 1–8)

• Some high school (grades 9–12, no degree)

• High school graduate, GED, or equivalent

• Some college (1–4 years, no degree)

• Associate’s degree (including occupational or academic degrees)

• Bachelor’s degree (BA, BS, AB, etc.)

• Master’s degree or higher (MA, MS, PhD, MD, etc.)

51. In the past 6 months, have you been told by a doctor or other health care professional that you have …?

    	Yes	No
    a. Anemia or low iron		
    b. Excessive weight gain		
    c. Diabetes, gestational diabetes, or high blood sugar		
    d. High blood pressure		

52. Are you currently working for pay either full time or part time?

• Yes, full time

• Yes, part time

• No

53. What language(s) do you speak at home? (Mark all that apply.)

• English

• Spanish

• Other

54. How many people live in your household right now?

    	Number (If none, write zero)
    a. Infants under 12 months of age
    b. Children 1–4 years of age
    c. Children 5–17 years of age
    d. Adults 18 years or older (include yourself)

55. How many people in your household are on WIC right now? Please include yourself. _____

56. Do you have regular childcare for your youngest child where someone other than you or your child’s other parent takes care of him/her on a regular basis?

• Child has not been born yet

• Yes  How many hours per week is your child usually in childcare? _____

• No

57. Which do you receive now? (Mark all that apply.)

• Supplemental Nutrition Assistance Program benefits, sometimes called SNAP or Food Stamps

• Temporary Assistance to Needy Families, sometimes called TANF or welfare

• Medicaid or ______________[INSERT STATE-SPECIFIC NAME FOR MEDICAID]

• Head Start

• Food from food bank, food pantry or soup kitchen

• Other food assistance program; Specify:________________________________

• I do not receive any assistance besides WIC

58. Which have you ever received but DON’T receive now? (Mark all that apply.)

• Supplemental Nutrition Assistance Program benefits, sometimes called SNAP or Food Stamps

• Temporary Assistance to Needy Families, sometimes called TANF or welfare

• Medicaid or ________________ [INSERT STATE-SPECIFIC NAME FOR MEDICAID]

• Head Start

• Food from food bank, food pantry or soup kitchen

• Other food assistance program; Specify:________________________________

• I have not received any assistance besides WIC

In the past 6 months, which topics did you discuss in WIC one-on-one or group sessions or watch in videos/DVDs or Web sites? (Mark all that apply.)			Put a check mark  for the topic you discussed or watched that was MOST helpful. (Put just ONE check mark.)
a. Breastfeeding			
b. Weaning from a bottle			
c. Drinking milk/choosing lower fat milk			
d. Drinking water			
e. Fruit and vegetables			
f. Healthy snacking			
g. Healthy weight for myself			
h. Introducing solid foods to my baby			
i. Medical conditions such as low iron or high blood sugar			
j. Physical activity			
k. Picky eaters			
l. Shopping for and preparing healthy foods			
m. Sodas and sugary drinks			
n. Whole grains			
o. None of the above	

Thank you for filling out the survey!

You will get another survey in several months.

Thank you for taking part in the WIC Nutrition Education Study (NEST)!