Z.1_Part Fact Sheet_English

OMB Control Number: 0584-XXXX

Expiration date: XX/XX/XXXX

APPENDIX Z.1:
PARTICIPANT SURVEY FACT SHEET—ENGLISH

Fact Sheet for RTI and WIC Staff to Distribute to Clients

Information on the WIC Nutrition Education Study

Do you get WIC benefits for you or a child?

If yes, you may be able to take part in a national research study on WIC nutrition education. To be eligible to participate, you must be 18 or older and be pregnant, postpartum, or a mother or caregiver of a child less than 4 years old. If you are eligible, you will get up to $50 in gift cards for completing three surveys over the next 12 months.

How can I take part in this study?

From MONTH XX to MONTH XX, study team members will be at your WIC clinic from TIME to TIME to sign you up. If possible, please arrive 20 minutes before your next scheduled WIC appointment time to enroll in the study and fill out a survey.

What do I have to do as part of the study?

When you come to your WIC clinic, study team members will ask you a few questions to make sure you are able to take part in the study. If you agree to take part, you will be asked for your contact information and to fill out a 20-minute survey. You will complete the first part of the survey before your WIC appointment, which will take 10 minutes, and the second part of the survey after your WIC appointment, which will take another 10 minutes. You will be asked to fill out two more surveys over the next 12 months. Both of those surveys will be mailed to you.

Will I receive a gift for participation?

You will get a $20 gift card after filling out the first survey. You will also get a $15 gift card for filling out the second survey and another $15 gift card for filling out the third survey.

What about my privacy?

All of your information will be kept private. We will use a study ID number instead of your name on study information, and you will not be named in any reports. You may refuse to answer any question, and you may quit the study at any time. Your participation in the study will not affect your WIC benefits.

How can I get more information about the study?

For more information, call 1-xxx-xxx-xxxx (toll-free) or send an email to [email protected]. A study team member will contact you.

You may also contact Karen Castellanos-Brown, the Project Officer at FNS, at [email protected] with questions or comments about the study.

RTI International is an independent, nonprofit research organization dedicated to conducting research that improves the human condition (www.rti.org).

Suggested Script for RTI Field Representatives’ Initial Contact with Prospective Participants

RTI field representatives will be stationed in each WIC site’s waiting room to screen and recruit participants, obtain informed consent, collect participants’ contact information, and collect baseline survey data (Section 1 before the client’s WIC appointment, and Section 2 after the client’s WIC appointment). A suggested script is provided below.

(Before WIC Appointment)

[WHEN PASSING OUT FACT SHEET] “This sheet provides information on a research study we are doing on WIC nutrition education. If you are eligible, you can get up to $50 in gift cards for filling out three surveys over the next 12 months. Today you will get a $20 gift card for filling out the first survey and $15 gift cards for filling out the second and third surveys. If you are interested in the study, I can tell you more about it.”

“Are you interested in taking part in our study?

Yes – Great! May I ask you a few questions to see if you qualify for the study? [ADMINISTER ELECTRONIC SCREENING QUESTIONNAIRE.]

No – Thank you for your time [CODE AS ### - REFUSAL BEFORE SCREENING.]

*Highlighted text may need to be adjusted based on the enrollment procedures for each site.

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 2 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.

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