WIC Participant

APPENDIX E.1

AGE 3 EXTENSION WIC INFANT AND TODDLER FEEDING PRACTICES STUDY – II

CONTACT INFORMATION FORM (27- & 33-months) - ENGLISH

	OMB Approval No. 0584-0580 Approval Expires: XX/XX/20XX Site # Keep in touch with Feeding My Baby!
PLEASE HELP US STAY IN TOUCH BY UPDATING YOUR CONTACT INFORMATION BELOW AND MAILING IT BACK TO US IN THE ENCLOSED ENVELOPE.

YOU WILL RECEIVE $5 ON YOUR PAYONEER CARD FOR RETURNING THE COMPLETED FORM.

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YOUR NAME

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STREET ADDRESS

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CITY STATE ZIPCODE

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PHONE

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CELL PHONE

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CAN WE TEXT YOU?  YES  NO

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EMAIL

PLEASE TELL US THE NAME AND CONTACT INFORMATION OF 2 PEOPLE WHO ALWAYS KNOW HOW TO FIND YOU:

#1. ____________________________________________________

NAME

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STREET ADDRESS

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CITY STATE ZIPCODE

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PHONE

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CELL PHONE

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EMAIL

#2. ____________________________________________________

NAME

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STREET ADDRESS

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CITY STATE ZIPCODE

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PHONE

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CELL PHONE

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EMAIL

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 0584-0580.  The time required to complete this information collection is estimated to average 6 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.