WIC NE Individuals/Household - Phase II

Appendix EE.1:
CaregiveR of Child baseline papi survey—English

For Project Staff Use Only: Section 1

ID:_____________ Child’s First Name ____________________

Date enrolled: _____/______/______

Last question before appointment: ____________

Date survey collected: _____/______/______ □ Site □ Mail

FR ID:__________ Paid? 

Baseline Survey for Participant with Eligible Child

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 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 and your child. 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. Please write in:

Name of child from label on front of survey: ______________________________

Please answer all survey questions about THIS child.

2. How old is your child?

• Less than 12 months old

• 1 year or older  GO TO Question 8

3. Are you currently breastfeeding your child?

• Yes

• No  GO TO Question 6

4. Think about how much longer you plan to breastfeed your child. How old do you expect your child to be when you stop breastfeeding?

____________ months

5. How sure are you that you can breastfeed your child until s/he is 1 year old?

• Not sure

• A little sure

• Very sure

6. How old was your child when you first introduced solid foods by spoon or in a bottle (things like infant cereal or baby food from a jar or homemade)?

• Less than 3 months old

• 4 months old

• 5 months old

• 6 months or older

• Has not eaten solid foods  YOU ARE DONE WITH SECTION 1. PLEASE GIVE YOUR SURVEY TO RESEARCH STUDY STAFF.

7. Does your child feed himself/herself any foods? That is, does your child pick up food and put it in his or her mouth without any help?

• Yes

• No

8. Different children like different foods. How much does your child like …?

	Never Tried	Doesn’t Like at All	Likes a Little	Likes a Lot
a. Vegetables (including baby food)				
b. Fruit (including baby food)				
c. Whole milk or 2% (reduced fat) milk				
d. Low-fat (1%) or fat-free/skim milk				
e. 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 your child ate or drank during the past month, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at school, in restaurants, and anyplace else.

9. In the past 30 days, how often did your child eat hot or cold cereals, including baby cereal?

• Never  GO TO Question 10

• 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

9a. In the past 30 days, what kind of cereal did your child usually eat? (Print the name of the cereal.)

9b. If there was another kind of cereal that your child ate in the past 30 days, what kind was it? (Print the name of the cereal, or if none, leave blank.)

10. In the past 30 days, how often did your child have any cow’s 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 12

• 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

11. In the past 30 days, what kind of milk did your child 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: ____________________________

12. In the past 30 days, how often did your child 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)									

13. In the past 30 days, how often did your child 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, include 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, include 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)									

13. In the past 30 days, how often did your child 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
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)									
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)									

14. All families are different and eat 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 to do it next month	Have been doing it for LESS than 6 months	Have been doing it for 6 months or LONGER
a. Serve your child vegetables (include baby food) at dinner every day					
b. Serve your child fruit (include baby food) for a snack instead of cookies or chips every day					
c. Serve your child low-fat (1%) or fat-free/skim milk instead of whole milk or 2% (reduced fat) milk every day (Answer only if child is 2 years or older.)					
d. Almost always serve your child whole grain bread instead of white bread					
e. Almost always serve your child brown rice instead of white rice					
f. Almost always serve your child whole wheat or corn tortillas instead of white flour tortillas					
g. Serve your child 100% juice NO MORE than once a day					
h. Serve your child regular soda or pop, sweetened fruit drinks, sports drinks or energy drinks NO MORE than once a month					

15. How sure are you that you can …?

	Not Sure	A Little Sure	Very Sure
a. Serve your child vegetables (include baby food) at dinner every day			
b. Serve your child fruit (include baby food) for a snack instead of cookies or chips every day			
c. Serve your child low-fat (1%) or fat-free/skim milk instead of whole milk or 2% (reduced fat) milk every day (Answer only if child is 2 years or older.)			
d. Serve your child whole grain bread instead of white bread			
e. Serve your child brown rice instead of white rice			
f. Serve your child whole wheat or corn tortillas instead of white flour tortillas			
g. Serve your child 100% juice NO MORE than once a day			
h. Serve your child 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 research study staff.

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

Please complete Section 2 of the survey now.

16. 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				

17. 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			

18. How often do these things happen? (Skip this question if your child has not eaten solid foods.)

	Rarely or Never	Some Days	Most Days	Almost Every Day	Every Day
a. My child eats a meal while watching TV/DVDs					
b. I sit and eat a meal with my child					
c. My child is picky about the foods s/he eats					
d. I cook a homemade dinner for my child at home					

19. How many times do you usually offer a new food before you decide your child does not like it?

• Once

• Twice

• 3–5 times

• 6–10 times

• More than 10 times

• My child likes everything

• My child hasn’t tried new foods

20. Below are some things that parents may do. In the past 30 days, how often did you do the following things?

	Almost Never	Once in a While	Sometimes	Often	Almost Always
a. Kept track of what my child eats and drinks					
b. Tried to get my child to finish his/her food and drinks					
c. Tried to get my child to eat even if s/he does not seem hungry					
d. Carefully controlled how much my child eats or drinks					
e. Talked to my child to encourage him/her to eat or drink					
f. Let my child eat desserts/sweets to keep him/her happy					
g. Put cereal in my child’s bottle (Answer only if child is younger than 12 months.)					

21. All families do things differently. Think about what you and your child 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. My child eats breakfast ___ times a week								
b. We eat out ___ times a week									
c. My child eats fast food ___ times a week									
d. My child plays outside ___ days a week								
e. My child plays outside ___ hours a day									
f. I play outside with my child ___ days a week								
g. My child watches TV or DVDs ___ hours a day									
h. I watch TV or DVDs ___ hours a day									
i. My child plays video or computer games ___ hours a day (including games played on phones and other handheld devices)									

22. 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 24

23. 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

24. 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
Encourage you to eat healthy foods					
Complain about eating healthy foods					
Encourage you to do physical activity					
d. Do physical activity with you					

25. 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					

26. Who in your family currently gets WIC benefits? (Mark all that apply.)

• Me, because I am pregnant

• Me, because I recently gave birth

• My baby who is less than 12 months old

• My child(ren) who are over 12 months old

• None of my family  GO TO Question 28

27. 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

28. 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

29. In the past 6 months, during WIC visit(s) how many times did you do …? 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							

30. In the past 6 months, in between WIC visits, what did you get from WIC with information on 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 WIC visit in which you got information on health or healthy eating.

31. 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

32. 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				

33. 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.

34. 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

35. 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:__________________________________

36. 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

37. 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 43

• Less than 5 minutes

• 5–15 minutes

• 16–30 minutes

• More than 30 minutes

Answer Questions 38 to 42 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 43.)

38. 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

39. 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

40. 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				

41. Did you talk about this topic in your one-on-one time? (Mark one box for each topic below.)				42. Have you made or do you think you will make a change to your child’s 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. Serving more fruit and vegetables							
b. Serving more whole grains like whole grain bread, whole wheat or corn tortillas, or brown rice							
c. Serving lower fat milk (1% or fat-free/skim milk) (Answer only if child is 2 years or older.)							
d. Encouraging more physical activity							
e. Preparing healthier foods for my family							
f. Providing water instead of soda and sugary drinks							

43. 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 49

• Less than 5 minutes

• 5–15 minutes

• 16–30 minutes

• More than 30 minutes

Answer Questions 44 to 48 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 49.)

44. 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.

45. 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

46. 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				

47. Did you talk about this topic in your group session? (Mark one box for each topic below.)				48. Have you made or do you think you will make a change to your child’s 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. Serving more fruit and vegetables							
b. Serving more whole grains like whole grain bread, whole wheat or corn tortillas, or brown rice							
c. Serving lower fat milk (1% or fat-free/skim milk) (Answer only if child is 2 years or older.)							
d. Encouraging more physical activity							
e. Preparing healthier foods for my family							
f. Providing water instead of soda and sugary drinks							

49. 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 54

Answer Questions 50 to 53 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 54.)

50. 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

51. 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: ____________________________

52. Did you read or view this topic on the WIC Web site? (Mark one box for each topic below.)				53. Have you made or do you think you will make a change to your child’s 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. Serving more fruit and vegetables							
b. Serving more whole grains like whole grain bread, whole wheat or corn tortillas, or brown rice							
c. Serving lower fat milk (1% or fat-free/skim milk) (Answer only if child is 2 years or older.)							
d. Encouraging more physical activity							
e. Preparing healthier foods for my family							
f. Providing water instead of soda and sugary drinks							

54. 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

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

• Married

• Widowed

• Divorced

• Separated

• Single or never married

• Living with partner

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

• Hispanic or Latino

• Not Hispanic or Latino

57. 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:________________________________

58. 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.)

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

	Yes	No
a. Was a preemie or premature as a baby		
b. Needs special infant formula		
c. Is low weight		
d. Is overweight		
e. Has high blood lead		

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

• Yes, full time

• Yes, part time

• No

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

• English

• Spanish

• Other

62. 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)

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

64. Do you have regular childcare for your child where someone other than a family member in your home takes care of him/her on a regular basis? (Answer for child identified on front of survey.)

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

• No

65. 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

66. 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

67. 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.)			68. 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 child			
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)!

EE-0