WIC Participant

OMB Approval No. 0584-0580

Approval Expires: XX/XX/20XX

APPENDIX J.1

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

36-MONTH INTERVIEW - ENGLISH

WIC ITFPS-2 Participant Interview

36 Month

October 28, 2014

CAREGIVER STATUS CONFIRMATION

Respondent still Caregiver?

1, 3, 5, 7, 9, 11, 13, 15, 18, 24, 30,36

SD12. Before we begin today, I need to ask whether you are still {CHILD's} caregiver. [Source: New Development]

YES 01 GOTO AMPM

NO 02 GOTO SD12a

a. Does {CHILD} still live with you?

YES 01 GOTO SD12b

NO 02 GOTO SD12c

b. (If a is Yes): Can you please tell me who in your household is now {CHILD's} caregiver? Can I speak with that person?

NAME OF NEW CAREGIVER______________________________________________

c. (If a is No): Can you please tell me who is caring for {CHILD} now, and how I could reach that person?

NAME OF NEW CAREGIVER

PHONE OF NEW CAREGIVER

ADDRESS OF NEW CAREGIVER

RELATION OF NEW CAREGIVER TO CHILD

CURRENT FEEDING PRACTICES

AMPM Module (Asking child’s food intake in past 24 hours)

24-HR Recall for Food Intake

1, 3, 5, 7, 9, 11, 13, 15, 18, 24, 36

NOTE: The 24-hour dietary recall follows different pathways for each person’s consumption, and thus the full content cannot be well expressed in a linear fashion like the rest of the participant interview. The interview is constructed such that the mother will be asked to recall all her child’s dietary intake for the previous day in a very systematic fashion. She will be guided through the day and asked to report all foods, beverages, dietary supplements and each eating event, which will be recorded by the interviewer.

The general questions are:

1. Please tell me everything {CHILD} had to eat and drink all day yesterday, {DAY}, from midnight to midnight. Include everything {CHILD} had at home and away, even snacks, drinks, bottles, breast milk, and water. I’ll ask you for specific details and amounts of the foods in a few minutes. At this time, just tell me what {CHILD} had.

2. You’re answers are important, so we’d like this list to be as complete as possible. In addition to the foods you have already told me about, did {CHILD} have any:

   1. Coffee, tea, soft drinks, milk or juice?

   2. Cookies, candy, ice cream or other sweets?

   3. Chips, crackers, popcorn, pretzels, nuts or other snack foods?

   4. Fruits, vegetables, or cheese?

   5. Breads, rolls, or tortillas?

   6. Anything else?

3. About what time did {CHILD} begin to eat/drink the {FOOD}?

4. What would you call this eating occasion? (Was it your breakfast, lunch, dinner, snack, or something else?)

5. When I ask how much {CHILD} ate, you can estimate the amount by using the drawings in the Food Model Booklet, the measuring cups and spoons, the ruler, and any of your own dishes and glasses. Feel free to check the labels on any food packages during the interview.

6. First, did {CHILD} have anything to eat or drink between midnight yesterday and her {FIRST EATING OCCASION}?

7. [The system will ask descriptive details about every food/beverage and then the amount eaten.]

8. Did you add anything to the {FOOD}?

9. Did you get (this/most of the ingredients for this) {FOOD} from the store?

10. Where did you get (this/most of the ingredients for this) {FOOD}? Was it from a restaurant, a fast food place, a community program, a friend, or something else?

11. For {MEAL} {CHILD} had {FOODS}. Did {CHILD} eat or drink anything else?

12. Did {CHILD} eat this {MEAL} at your home?

13. Did {CHILD} eat or drink anything between her {TIME, MEAL} and her {NEXT TIME, MEAL}?

14. Did {CHILD} eat or drink anything between her {LAST TIME, MEAL} and midnight last night?

15. Do you remember anything else {CHILD} drank, including water, or that she ate yesterday – even small amounts, anything she ate in the car, or while shopping, cooking or cleaning up?

16. Was the amount of food that {CHILD} ate yesterday much more than usual, usual, or much less than usual?

17. When {CHILD} drinks tap water, what is the main source of the tap water. Is it the city water supply (community water supply); a well or rain cistern; a spring; or something else?

18. What type of salt does {CHILD} usually add to her food at the table? Would you say it is ordinary or seasoned salt, lite salt, or a salt substitute?

19. How often does {CHILD} add ordinary, sea, seasoned, or other flavored salt to her food at the table?

20. How often is ordinary salt or seasoned salt added in cooking or preparing foods in your household?

21. Is {CHILD} currently on any kind of diet, either to lose weight or for some other health-related reason?

22. The next questions are about {CHILD}’s use of dietary supplements, including prescription and over the counter supplements. All day yesterday, {DAY}, between midnight and midnight, did {CHILD} take any vitamins, minerals, herbals or other dietary supplements?

23. Can you please locate the containers for all the dietary supplements {CHILD} took? Can you please read to me all the words on the front label?

24. The next questions are about {CHILD}’s use of non-prescription antacids. All day yesterday, {DAY}, between midnight and midnight, did {CHILD} take any antacids?

25. Can you please locate the containers for all the antacids {CHILD} took? Can you please read to me all the words on the front label?

SOCIODEMOGRAPHICS AND BACKGROUND

I’d like to ask you some background questions about yourself and your family.

Marital status

Baseline, 13, 30, 36

SD14. Are you …? [Source: WIC IFPS-1]

Married 01

Separated 02

Divorced 03

Widowed 04

Or Never Married 05

Don’t know 98

Refused 99

Continuation/discontinuation of WIC participation (timing, reasons, location)

1, 3, 5, 7, 9, 11, 13, 15, 18, 24, 30, 36

Next I’d like to ask you some questions about WIC.

SD31. Are you currently getting WIC food or checks for yourself or {CHILD}? [Source: FDA IFPS-2; modified]

YES 01

NO 02

SD45. Are you currently getting WIC food or checks for any infants or children other than {CHILD}? [Source: New development]

YES 01

NO 02

(If SD31 = Yes, go to SD32 after SD45; If SD31 = No for the first time, go to SD34 after SD45; if SD31 = No now and no previously go to SD21 after SD45.)

SD32. The last time we talked with you, you were going to WIC at [fill in location]. Do you still go there, or do you go to a new location? [Source: FDA IFPS-2 modified]

YES, STILL THAT LOCATION 01 GOTO SD21

NO, NEW LOCATION 02 GOTO SD33

SD33. (If SD32 is no) Please tell me where you go now

RECORD LOCATION _______________________________________

Ask SD34 and SD35 only if SD31 is 'no' for the first time

SD34. How old was {CHILD} when you stopped going to WIC? [Source: LA WIC Survey; modified]

Age [weeks/months]

SD35. I'm going to read some reasons why you might have stopped going to WIC. Please tell me if each one is a reason you stopped going to WIC: [Source: LA WIC Survey; modified]

1. You no longer qualify for WIC?

YES 01

NO 02

2. It was inconvenient for you?

YES 01

NO 02

3. You no longer need WIC?

YES 01

NO 02

4. Is there any other reason?

YES 01

NO 02

(IF YES): [What is the other reason you stopped going to WIC?]

SPECIFY __________________________________________________________

Receipt of public assistance

Baseline, 13, 24, 30, 36

SD21. Are you or your family currently receiving any of the following: [Source: WIC IFPS-1; modified]

a. Supplemental nutrition assistance benefits, sometimes called SNAP or Food Stamps?

YES 01

NO 02

DON’T KNOW 98

b. Temporary assistance to needy families, sometimes called TANF or welfare?

YES 01

NO 02

DON’T KNOW 98

c. Are you receiving Medicaid or [state specific name for medicaid]?

YES 01

NO 02

DON’T KNOW 98

d. Are any children in your household receiving free or reduced price meals from the National School Lunch or School Breakfast Program, or the Summer Foods Program?

YES 01

NO 02

DON’T KNOW 98

Household size

Enrollment, 7, 13, 24, 30, 36

SD18. How many people live in your household? By household I mean people who live together and share living expenses. Please include yourself in this count, and (If PN enrollment: please add 1 to the total for your pregnancy, too/If postnatal enrollment or 7, 13, 24, 30 or 36 months: If you are pregnant right now please add 1 to the total for your pregnancy. [Source: FITS 2002, modified]

NUMBER OF PEOPLE IN HOUSEHOLD [number]

Household income

Enrollment, 7, 13, 24, 30, 36

SD19. During [PREVIOUS MONTH], what was your household income before taxes? Please include any income in the past month from you, your family members who live with you, and any other people who live with you and share living expenses with you [Source: WIC IFPS-1, modified]

INCOME [amount]

(OR if respondent cannot provide specific amount): I’ll read some ranges, and you can stop me when I get to the one that is your best estimate of your household income before taxes for [PREVIOUS MONTH]

$500 or less 01

$501-$1000 02

$1001-$1500 03

$1501-$2000 04

$2001-$2500 05

$2501-$3000 06

$3001-$3500 07

$3501-$4000 08

$4001-$4500 09

$4501-$5000 10

$5001+ 11

Don’t know 98

Refused 99

6-Item Food Security

Enrollment, 7, 13, 18, 24, 30, 36

These next questions are about the food eaten in your household in the last 12 months, since {name of current month} of last year and whether you were able to afford the food you need.

SD36. I’m going to read you several statements that people have made about their food situation. For these statements, please tell me whether the statement was often true, sometimes true, or never true for your household in the last 12 months—that is, since last (name of current month). [Source: USDA food security 6-item]

The first statement is, “The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for your household in the last 12 months?

OFTEN TRUE 01

SOMETIMES TRUE 02

NEVER TRUE 03

DON’T KNOW 98

REFUSED 99

SD37. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for your household in the last 12 months?

OFTEN TRUE 01

SOMETIMES TRUE 02

NEVER TRUE 03

DON’T KNOW 98

REFUSED 99

SD38. In the last 12 months, since last (name of current month), did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?

YES 01  GOTO SD38a

NO 02  GOTO SD39

DON’T KNOW 98  GOTO SD39

a. [if yes to SD38, ask] How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?

ALMOST EVERY MONTH 01

SOME MONTHS BUT NOT EVERY MONTH 02

ONLY 1 OR 2 MONTHS 03

DON’T KNOW 98

SD39. In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?

YES 01

NO 02

DON’T KNOW 98

SD40. In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food?

YES 01

NO 02

DON’T KNOW 98

Currently pregnant/due date

7, 13, 18, 30, 36

SD16. Are you currently pregnant? [Source: New Development]

YES 01  GOTO SD17

NO 02 GOTO CM9

DON’T KNOW 98 GOTO CM9

REFUSED 99 GOTO CM9

SD17. (If yes) When is your baby due? [Source: FDA IFPS-2]

MONTH [JANUARY – DEC.]

DAY [1-31]

{Year – autofill for next occurrence of the month}

Caregiver report of child weight and height

30, 36

CH21. The last time {CHILD} was weighed, how much did [he/she] weigh? [Source: New development]

POUNDS [number]

OR

KILOGRAMS [number]

DON’T KNOW 98  GOTO CH24

REFUSED 99  GOTO CH24

CH22. When was that weight taken? Please give me the month and year. [Source: New development]

MONTH [Jan-Dec]

YEAR [number]

DON’T KNOW 98

REFUSED 99

CH23. Where was {CHILD}’s weight taken? Was it… [Source: NC CHAMPS, modified]

At home 01

In a doctor’s office 02

At the WIC site or clinic 03

Or some other place 04

CH24. The last time {CHILD}’s height was measured, how tall was [he/she]? [Source: New development]

INCHES [number]

OR

CENTIMETERS [number]

DON’T KNOW 98  GOTO CH21

REFUSED 99  GOTO CH21

CH25. When was that height measurement taken? Please give me the month and year. [Source: New development]

MONTH [Jan-Dec]

YEAR [number]

DON’T KNOW 98

REFUSED 99

CH26. Where was {CHILD}’s height measured? Was it… [Source:NC CHAMPS, modified]

At home 01

In a doctor’s office 02

At the WIC site or clinic 03

Or some other place 04

HEALTH CARE PROVIDER INFORMATION UPDATE

CM9. As we mentioned when you first joined the study, we’d like to get information from {CHILD}’s doctor, and you gave us permission to do that. Can I please have the name of your child’s doctor, the doctor’s phone number if you have it, and the city and state where the doctor’s office is?

DOCTOR’S NAME

LOCATION

PHONE

CHILD HASN’T SEEN A DOCTOR 97

DON’T KNOW 98

REFUSED 99

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 30 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.