NSWP III (IC 2 of 2)

REVISED

Third National Survey of WIC Participants (NSWP-III)

Capital Consulting Corporation

2M Research Services

Abt Associates Inc.

Order # AG-3198-K-15-0077

Tony Panzera, COR

June 15, 2016

Deliverable 3.2.2 REVISED Certification Survey

With Instructions to Interviewers and Reviewers

Table of Contents

Certification Survey for WIC Participants: Version A (Women) 2

Certification Survey for WIC participants: Version B (Infant/Child) 39

Certification Survey for WIC Participants: Version A (Women)

The NSWP-III Certification Survey has two versions. Version A is used when the sampled participant is a pregnant, breastfeeding or postpartum, non-breastfeeding woman. Version B (included after Version A) is used when the participant is an infant or child. The survey respondent for Version B is the adult who applied for WIC for the infant or child.

Instructions for Reviewers

The Certification Survey will be administered by trained Field Interviewers (FIs). After the pretest results the survey will be implemented in a Computer Assisted Personal Interview (CAPI) format programmed onto study laptops. This paper version approximates the layout of the CAPI questionnaire and includes notes indicating how the CAPI system will automatically route the interviewer to the appropriate questions or data entry forms, or performs specified calculations (these notes appear in the paper version in RED, CAPITALIZED text but will not appear in the CAPI version). In addition, the CAPI version will be programmed to pre-populate certain data about each participant sampled for the Certification Survey; these data elements appear in Table 2 on the next page.

The NSWP-III version of the Certification Survey is adapted from the version used in NSWP-II. This is motivated by an effort to minimize differences in data collection to allow meaningful comparison of the estimates of improper payment errors between the two studies. The survey is organized into the following modules:

Table 1: Certification Survey Modules
Name	Purpose
Identity	Document proof of identity
Residency	Document proof of residency
Category	For Infant or Child participants, confirm participant category
Income	Determine the size of the participant’s family economic unit (SURVEY_EU_SIZE); Collect documentation of income sources
End survey	Thank participant and conclude survey
Military Pay Module	Module to assist in determining income and exclusions for military service members
Income Probe Module	Questions in the event one or more reported income sources may be subject to WIC income exclusion regulations

Typically, FIs will administer the five numbered modules in order, but FIs may navigate between modules as needed during survey administration. The two final modules are supplementary, included for use by FIs if needed. The Military Pay module assists FIs in correctly including or excluding income from pre-specified pay codes (e.g., combat pay codes and FSSA are excluded) or querying if a military pay “allowance” is a lump sum paid other than monthly. The Income Probe module includes questions FIs will ask if a respondent reports income that may come from a source that must be excluded per federal WIC regulations.

Text that FIs read aloud (questions, response options where indicated) appear in regular text, while on-screen instructions to FIs appear in CAPITALIZED TEXT.

Table 2. Data Pre-Populated into the Computer-Assisted Personal Interview (CAPI) system for each Participant in the Sample
Variable	Description
PARTICIPANT	Name of certified WIC participant (Last, First, Middle)
APPLICANT	Name of Certification Survey applicant if PARTICIPANT is infant or child
ADDRESS	Participant’s address (number, street, apartment number, city, state, zip code)
STATE	Participant listed in this State’s WIC participant data
STATE_ID	State WIC Agency identifier
LOCAL_ID	Local WIC Agency identifier
CLINIC_ID	Local clinic identifier
ITO	Yes/No, Participant is from an ITO or an LWA run by an Indian organization or Indian Health Service
CERT_CAT	Participant’s category (as assigned by WIC) P=pregnant; B=breastfeeding; N=not breastfeeding postpartum; INF=infant; C=child
CERT_DATE	Start date of most recent certification period
CERT_EXPIRES	End date of certification period
CERT_PERIOD	Number of days of most recent certification period (1 to 365)
	30 days 60 days 90 days 120 days	1 month 2 months 3 months 4 months	150 days 180 days 210 days 240 days	5 months 6 months 7 months 8 months	270 days 300 days 330 days 360+ days	9 months 10 months 11 months 12 months
ADJUNCTIVE	Yes/No, Participant was certified as adjunctively income eligible by WIC
AUTOMATIC	Yes/No, Participant was certified as automatically income eligible by WIC
ADJC_PRG	Name of program that made participant adjunctively eligible
AUTO_PRG	Name of program that made participant automatically eligible
MIGRANT	Yes/No, Participant is a migrant worker
EU_SIZE	Economic Unit size -- number of persons in participant’s family Economic Unit
EU_ADULT	Number of persons aged 15 years or older in participant’s EU
EU_CHILD	Number of persons younger than 15 years in participant’s EU
PREG_NUM	Number of expected live births: if SINGLETON, PREG_NUM=1; if TWINS, PREG_NUM=2; etc.

Certification Survey for WIC participants (Version A: Women)

Version A: Pregnant, Breastfeeding, and Postpartum Women

THE FOLLOWING INFORMATION WILL BE AVAILABLE TO INTERVIEWER WHILE ADMINISTERING THE SURVEY:

Last­_Name				First_Name		Participant Category		Certification Date (CERT_DATE)	Certification Period	Prior WIC Participant?	Migrant?
Doe				Jane		P/B/N/INF/C		mm/dd/yy	xx days/months	Yes/No	Yes/No
State:	MN		City:	Anytown		ZIP:	12345	Street:	100 Main Street
Reciprocity?			Yes/No	Participant of WIC in which State:		ST	Participant’s LWA:		Local Agency where participant receives WIC benefits, services
Family (EU) Size			#	Adjunct/Auto Elig?		Y/N	Adjunctive program name:
ITO?			Yes/No	Use alternate income procedure?			Yes/No
IF PARTICIPANT IN ITO OR SERVED BY ITO OR LIVES IN INDIAN VILLAGE:
Village						Reservation or Sovereign Nation
State:		City:			Anytown	ZIP:		PO Box:

INTRO: Hi. Thanks for agreeing to do this survey. We will keep your answers private to the extent allowed by law. None of the information you share with me will cause your WIC benefits to change. The purpose of the survey is to help get a better idea of who participates in the program and their family’s circumstances. After we finish, I will give you a $25 gift card to thank you for your participation. Before we start, we need to review this form together. It tells you about your rights as a study participant. It tells you how we will protect your privacy and how we will use your answers.

READ INFORMED CONSENT STATEMENT AND GET SIGNED CONSENT BEFORE PROCEEDING.

Field Interviewer confirmation at end of survey:

I met with participant at the following address on the date below: MAKE ANY CORRECTIONS IN THE ROW BELOW								INITIALS
State:	MN	City:	Anytown	ZIP	12345	Street	100 MAIN STREET
						Date	mm/dd/yy

• Location was a residential address

• Location was a non-residential address (e.g., library, business, community center). PROVIDE NAME OF LOCATION:

IDENTITY

1. The first thing we need is some identification for you. [IF PARTICIPANT HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF ID FROM LIST.]

HAS IDENTIFICATION?

 YES GO TO 1A

 NO IF PRIOR_WIC_PARTICIPANT=YES, GO TO 1B. IF PRIOR_WIC_PARTICIPANT=NO, GO TO 1C

1A. IF NAME MATCHES WIC RECORD CHECK OFF ID SHOWN AND GO TO NEXT MODULE

IF ID NAME DIFFERS: “The name on this ID doesn’t match my records. Can you show me another form of ID that has your name?”

Identification proofs [CHECK AT LEAST ONE]			ID shown during survey	ID shown at WIC
Driver’s license w/photo & name				
State or tribal-issued license or ID w/photo & name				
U.S. or foreign passport w/photo and name				
Work, school, military, or bus pass ID w/photo & name				
WIC ID card or WIC folder (PRIOR WIC PARTICIPANTS only; EBT cards are NOT valid proof of identity)				
Letter from government agency (including WIC) w/name				
Bank statement showing name				
Utility bill, rent/mortgage receipt, lease, w/name				
Social Security or Green card (or other Immigration document with name)				
Other: SPECIFY	
FI Notes		FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

1B. (PRIOR_WIC_PARTICIPANT = YES): “Ok, the records I have show that you most recently certified for WIC on CERT_DATE, and that you were receiving WIC benefits before that. Can you show me a WIC ID card or something else from WIC that has your name?” [TRANSFER/VERIFICATION OF CERTIFICATION NOT ACCEPTABLE PROOF OF IDENTITY]

• WIC FOLDER GO TO 1A

• OTHER DOCUMENT FROM WIC WITH NAME/ADDRESS GO TO 1A

• NEITHER GO TO 1C

1C. (PRIOR_WIC_PARTICIPANT = NO) OR 1B=NEITHER:

“Was your ID recently stolen, did you recently lose your ID? Have you recently been homeless, or experienced a fire, flood, hurricane, tornado, or similar event?”

 STOLEN/LOST GO TO 1D

 HOMELESS GO TO 1D

 DISASTER VICTIM GO TO 1D

 {State specific reason providing ID = unreasonable burden} GO TO 1D

 NONE OF THE ABOVE GO TO 1D

1D. “At your recent WIC certification appointment (on or before CERT_DATE), did you show any identification then?” (IF YES: Do you recall what type of ID you showed?)

 SHOWED ID AND RECALLS TYPE CHECK OFF ID SHOWN AT WIC IN IDENTIFICATION PROOF TABLE AND GO TO NEXT MODULE

GO TO NEXT MODULE.

30-day CERT_PERIOD and NO ID SHOWN = NO ERROR.

Else, NO ID SHOWN = ID ERROR

 SHOWED ID BUT NO RECALL OF TYPE

 DID NOT SHOW ID

 DO NOT RECALL

RESIDENCY: GEOGRAPHIC STATE

IF PARTICIPANT FROM ITO OR LIVES IN REMOTE INDIAN VILLAGE OR PUEBLO THEN CAPI WILL SKIP TO “ALTERNATE PROOF OF RESIDENCY.” ELSE CONTINUE WITH RESIDENCY: GEOGRAPHIC STATE PROCEDURE.

IF IDENTIFICATION SHOWN AS PROOF OF IDENTITY HAS ADDRESS AND IS AN ACCEPTED PROOF OF RESIDENCY, MARK OFF THE TYPE OF RESIDENCY PROOF IN TABLE BELOW AND SKIP TO INCOME ELIGIBILITY MODULE. OTHERWISE GO TO QUESTION 2.

2. “Next, I need some kind of proof that you live here. Do you have a utility bill, lease, or letter addressed to you?” MAIL MUST HAVE RESIDENTIAL ADDRESS. P.O. BOX DOES NOT = PROOF OF RESIDENCY. RURAL ROUTE BOX NUMBER IS ACCEPTABLE PROOF OF RESIDENTIAL ADDRESS.

HAS PROOF OF RESIDENCY?

YES GO TO 2A

NO IF PRIOR_WIC_PARTICIPANT=YES, GO TO 2B. IF PRIOR_WIC_PARTICIPANT=NO AND MIGRANT=YES, GO TO 2C(i); IF PRIOR_WIC_PARTICIPANT=NO AND MIGRANT=NO, GO TO 2C(ii)

2A. IF NAME AND ALL ADDRESS FIELDS MATCH WIC RECORD, CHECK OFF RESIDENCY PROOF AND GO TO NEXT MODULE.

IF ADDRESS FIELDS MATCH AND NAME DIFFERS, GO TO 2D.

IF ANY ADDRESS FIELD DIFFERS, GO TO 2E.

Residency proofs [CHECK AT LEAST ONE]			Shown during survey	Shown at WIC
Driver’s license with name & address				
State or tribal-issued license or ID w/name & address				
Utility bill, rent/mortgage receipt, or lease w/name & address				
Letter from government agency (including WIC) w/name & address				
Postmarked mail from reliable third party w/name & address				
OTHER: specify PROOF shown AT WIC: DURING SURVEY:				
FI Notes		FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

2B. (PRIOR_WIC = YES): “Ok, the records I have show that you were most recently certified for WIC on CERT_DATE, and that you were receiving WIC benefits before that. Can you show me a WIC ID card or something else from WIC that has your name and address?

• WIC FOLDER GO TO 2A

• OTHER DOCUMENT FROM WIC WITH NAME/ADDRESS GO TO 2A

• NEITHER GO TO 2C

2C(i). (PRIOR_WIC = NO AND MIGRANT =YES): “Do you, or does anyone in your household, work on farms and move from place to place as the season changes?” IF NECESSARY: “WIC agencies have special rules for families include a migrant farmworker who moves around the country depending on where there is work based on the growing season.”

• YES (MIGRANT FARMWORKER) GO TO 2F

• NO GO TO 2C(ii)

2C(ii) (PRIOR_WIC = NO OR 2B=NEITHER OR 2E=NO): “Did you recently lose documents with your address or were they stolen? Have you recently been homeless, or recently experienced a fire, flood, hurricane, tornado, or similar event?”

 STOLEN/LOST GO TO 2F

 HOMELESS GO TO 2F

 DISASTER VICTIM GO TO 2F

 {State specific reasons providing proof = unreasonable burden} GO TO 2F

 NONE OF THE ABOVE GO TO 2F

2D. (ADDRESS MATCHES BUT NAME DIFFERS): “This has an address, but someone else’s name. Do you have something with your name and address?” READ LIST IN 2A FOR EXAMPLES OF OTHER TYPES OF DOCUMENTS FOR RESIDENCY PROOF.

2E. (ADDRESS DIFFERS OR NAME AND ADDRESS DIFFER): “Ok, the [name and] address on this document doesn’t match my records.

Have you moved since CERT_DATE? Just as a reminder, WIC won’t know any personal information you share with me, including whether or not your address has changed.”

• YES (RECENTLY MOVED) ENTER INFO BELOW AND GO TO 2F

• NO (DID NOT RECENTLY MOVE) REVERSE TO 2C

State:

ZIP:

ADDRESS IS A STREET ADDRESS (Not PO Box)?

 Yes  No

2F. “At your recent WIC certification appointment, did you show anything with your name and address then?” (IF YES: “Do you recall what type of document you showed?”)

 SHOWED PROOF AND RECALLS TYPE CHECK OFF PROOF SHOWN AT WIC ON RESIDENCY PROOF TABLE AND GO TO NEXT MODULE

GO TO NEXT MODULE.

30-day CERT_PERIOD and NO PROOF SHOWN = NO ERROR.

Else, NO PROOF SHOWN = RESIDENCE PROOF ERROR

 SHOWED PROOF BUT NO RECALL OF TYPE

 DID NOT SHOW PROOF

 DO NOT RECALL

RESIDENCY: ALTERNATE PROCEDURE (ITO OR REMOTE INDIAN VILLAGE/PUEBLO)

ALTERNATE PROCEDURE APPLIES ONLY IF PARTICIPANT FROM ITO OR LIVES IN REMOTE INDIAN VILLAGE OR PUEBLO “ALTERNATE PROOF OF RESIDENCY PROCEDURE” APPLIES. ELSE USE RESIDENCY: GEOGRAPHIC STATES

ALTERNATIVE RESIDENCY PROCEDURE: GET VILLAGE NAME AND MAILING ADDRESS.

IF WIC RECORDS SHOW A RESIDENTIAL STREET ADDRESS (NOT A PO BOX), GO TO ALT 2A.

IF WIC RECORDS SHOW A PO BOX AND DO NOT SHOW VILLAGE, GO TO ALT 2B.

IF WIC RECORDS DO NOT SHOW A PO BOX AND SHOW A VILLAGE, GO TO ALT 2B.

IF WIC RECORDS SHOW A PO BOX AND SHOW A VILLAGE, GO TO ALT 2D.

ALT 2A. “At your most recent visit to the WIC office, did you have to show a document with your home address?”

YES “What type of document did you show?” GO TO RESIDENCY: GEOGRAPHIC STATE AND ENTER PROOF SHOWN AT WIC

NO GO TO ALT 2B

ALT 2B.	“What is the name of the town, village or pueblo where you live?”
Village from WIC records		Matches WIC records?
Village		Yes	No

IF VILLAGE NAME MATCHES WIC RECORDS, GO TO ALT 2D. IF NO VILLAGE IN WIC RECORDS OR PARTICIPANT RELUCTANT TO GIVE VILLAGE NAME GO TO ALT 2D. IF VILLAGE NAME GIVEN DOESN’T MATCH GO TO ALT 2C.

ALT 2C. “My records say that you were living in [VILLAGE].

(i) is there another name for the place you live?

• YES (RECORD NAME) GO TO ALT 2D

• NO GO TO ALT 2C(ii)

ALT 2C.

(ii) Did you recently move? Just as a reminder, WIC won’t know any personal information you share with me, including whether or not where you live has changed.”

• YES (RECENTLY MOVED) GO TO ALT 2D

• NO (DID NOT RECENTLY MOVE) GO TO ALT 2D

ALT 2D. MAILING ADDRESS: “What is your current mailing address?”

Mailing address from WIC records
P.O. Box or Street Address	P.O. Box NN	State	MN	ZIP	ZZZZZ
City	Anywhere
IF MAILING ADDRESS DIFFERENT FROM WIC RECORDS
Gave mailing address	 Yes  No
City		State		ZIP

IF MAILING ADDRESS MATCHES WIC RECORDS, GO TO NEXT MODULE. IF NO MAILING ADDRESS IN WIC RECORDS OR RELUCTANT TO GIVE MAILING ADDRESS, GO TO NEXT MODULE.

IF MAILING ADDRESS GIVEN DOESN’T MATCH WIC RECORDS, GO TO ALT 2E.

ALT 2E. (CHANGE OF MAILING ADDRESS) “Did you recently change your mailing address? Remember, WIC won’t know any personal information you share with me, including any change in your mailing address.”

• YES GO TO NEXT MODULE

• NO GO TO NEXT MODULE

FI Notes



FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

PARTICIPANT CATEGORY

[No data will be collected to confirm participant category for Pregnant, Breastfeeding or Postpartum WIC participants. See Version B for Infant/Child WIC participants]

INCOME ELIGIBILITY

HOUSEHOLD ENUMERATION

“Next, I’m going to ask you to tell me the names of all the people who were living or staying with you in [MONTH OF CERT_DATE] and whether they are related to you or not. I’ll type the names so that I can follow up with some questions. Please list only people who were living with you in [MONTH OF CERT_DATE].”

RECORD EACH NAME IN THE LIST BELOW. ENTER FIRST NAME ONLY.

1. PROBE FOR ADDITIONAL PERSONS: Anyone else?

2. Is [NAME] male or female?

3. How old is [NAME]?

4. What is [NAME]’s relationship to you?

Q1	Q2	Q3	Q4	Relationship Codes
NAME	GENDER 1=male 2=female	AGE in years	RELATIONSHIP	1=spouse 2=partner 3=child 4=step-child 5=adopted child 6=parent 7=step-parent 8=legal guardian 9=brother/sister 10=grandparent	11=uncle/aunt 12=cousin 13=nephew/niece 14=parent in-law 15=brother-in-law/sister-in-law 16=other relative 17=non-relative 18=child in temporary care 19=foster child 20=foster parent 21=sampled WIC participant
NAME OF WIC PARTICIPANT			21

ANYONE ELSE? 

FI MAY CLICK FOR ADDITIONAL ROWS AT ANY TIME DURING THE INTERVIEW. CAPI will add additional rows one at a time, up to 20 persons.

IF ANY Q4= 19 [HOUSEHOLD INCLUDES A FOSTER CHILD WHO SHOULD BE EXCLUDED FROM SAMPLED ECONOMIC UNIT], DISPLAY Q4FOSTER(ii): “When you applied for WIC, did you tell WIC that [NAME OF HOUSEHOLD MEMBER where Q4=19] is a foster child?  YES NO

FAMILY MEMBERS TEMPORARILY AWAY

“Other than people already listed, is there anyone who typically lives here but who was temporarily away in [MONTH OF CERT_DATE]?” (IF NECESSARY, PROBE: “For example, this could be a military service member on active deployment, someone who is in the hospital, a child away at school, or a child who lives part-time with each parent. Is there anyone who typically lives here but who was temporarily away?”)

• Yes ADD MEMBERS TEMPORARILY AWAY

• No GO TO CHILDREN IN TEMPORARY CARE

1. LIST NAME OF EACH PERSON TEMPORARILY AWAY

2. “Is [NAME] male or female?”

3. “How old is [NAME]?”

4. “What is [NAME]’s relationship to you?”

Q4B. “Can you tell me the main reason this person was temporarily away?” DO NOT READ LIST. PROBE FROM LIST IF NECESSARY.

1=MILITARY MEMBER ON ACTIVE DEPLOYMENT

2=IN THE HOSPITAL/REHAB OR TREATMENT CENTER/HALFWAY HOUSE

3=LIVING AWAY AT SCHOOL (BOARDING SCHOOL, COLLEGE)

4=CHILD LIVES PART-TIME IN HOUSEHOLD

5=OTHER, SPECIFY [DO NOT LIST ANY PERSON WHO WAS IN JAIL/PRISON IN MONTH OF CERT_DATE]

Members temporarily away
Q1A	Q2A	Q3A	Q4A	Relationship Codes		Q4B	Q4C
NAME	GENDER	AGE	RELATIONSHIP	1=spouse 2=partner 3=child 4=step-child 5=adopted child 6=parent 7=step-parent 8=legal guardian 9=brother/sister 10=grandparent	11=uncle/aunt 12=cousin 13=nephew/niece 14=parent in-law 15=brother-in-law/sister-in-law 16=other relative 17=non-relative 18=child in temporary care 19=foster child 20=foster parent	REASON TEMPORARILY AWAY	if 4B=4: WHERE CHILD LIVES MOST

IF 4B=5, CAPI WILL DISPLAY APPROPRIATE 4C QUESTION:

Q4C. IF 4B=5: “Where does [NAME] live most of the time: READ LIST

1= More than half of the time here in this household

2= More than half of the time in another household

3=About equal time here and in another household

If STATE AGENCY INCLUDES CHILDREN IN TEMPORARY CARE IN FAMILY ECONOMIC UNIT, CAPI WILL SKIP THIS MODULE

If STATE AGENCY EXCLUDES CHILDREN IN TEMPORARY CARE FROM FAMILY ECONOMIC UNIT, CAPI WILL DISPLAY THIS MODULE

CHILDREN IN TEMPORARY CARE

IF STATE AGENCY EXCLUDES CHILDREN IN TEMPORARY CARE OF FRIENDS OR RELATIVES FROM THE FAMILY ECONOMIC UNIT, AND THERE ARE ONE OR MORE CHILDREN AGED 15 OR YOUNGER IN THE HOUSEHOLD, THEN ASK:

“Sometimes, children stay with another family who takes care of them temporarily. Does this apply to any of the children you’ve listed? I’m going to read the name of each child who is 14 years old or younger. If you/your family were providing temporary care to that child in [MONTH OF CERT DATE], please answer ‘Yes.’”

LIST OF CHILDREN WHERE AGE < 15 YEARS AND CHILD IS NOT A FOSTER CHILD

“Were you or your family, providing temporary care to:

NAME OF first CHILD	 Yes	Q4 SET TO 18 CHILD WILL BE EXCLUDED FROM EU
NAME OF second CHILD	 Yes	Q4 SET TO 18 CHILD WILL BE EXCLUDED FROM EU
…

SHARED OR SEPARATE FINANCES

CAPI WILL AUTOMATICALLY DISPLAY NAME, GENDER, AGE AND (IF APPLICABLE) REASON TEMPORARILY AWAY OF EACH PERSON. INTERVIEWER WILL READ THE AGE-APPROPRIATE QUESTION AND SELECT RESPONSE IN COLUMN Q6:

“Next, I’m going to ask whether you shared income and expenses with each person who was living here in [MONTH OF CERT_DATE].”

IF AGE ≥ 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF CERT_DATE], you were sharing income and expenses as if you were a family – OR do you feel that you each kept your income and expenses and food separately?”

• Yes, share: SELECT “SHARE LIKE FAMILY” FOR NAME

• No, keep separate: SELECT “SEPARATE” FOR NAME

IF AGE < 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF CERT_DATE], you were responsible for taking care of them as if you were all in the same family?”

• Yes, responsible for taking care of: SELECT “SHARE LIKE FAMILY” FOR NAME

• No, not responsible for taking care of: SELECT “SEPARATE” FOR NAME

PREFILLED					INTERVIEWER SELECTS
	Q1	Q2	Q3	Q4B	Q6
	NAME	GENDER	AGE	REASON TEMPORARILY AWAY	Family or Separate?1
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	(1-6 code)	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	(1-6 code)	 1=share like family  2=separate

IF NECESSARY FOR MEMBERS TEMPORARILY AWAY, PROBE:

• NAME IS AGE ≥ 15 YEARS: “When [NAME] is here, do you and [NAME] share income and expenses?”

• NAME IS AGE < 15 YEARS: “When [NAME] is here, do you help take care of [NAME] as if you were all in the same family?”

PREGNANT FAMILY MEMBERS

P1. “Were you, or was anyone in your household, pregnant at your recent certification appointment at the WIC office?

• Yes GO TO P2

• No GO TO CONFIRM SIZE OF FAMILY EU

P2. “Who was pregnant on CERT_DATE?”
<SELECT NAME FROM Q1 LIST DROPDOWN MENU>	IF PREGNANT MEMBER SHARES FINANCES (Q6=1), GO TO P2A. IF PREGNANTMEMBER HAS SEPARATE FINANCES (Q6=2), GO TO P2D

P2A. “Were you/Was [NAME] expecting a single infant, twins or multiples?” (DO NOT READ OPTIONS)

• SINGLETON IF SHARED FINANCES, CAPI WILL ADD 1 TO FAMILY ECONOMIC UNIT. GO TO P2B

• TWINS IF SHARED FINANCES, CAPI WILL ADD 2 TO FAMILY ECONOMIC UNIT. GO TO P2B

• MULTIPLES [ENTER NUMBER FROM 3 OR HIGHER] IF SHARED FINANCES, CAPI WILL ADD [N] TO FAMILY ECONOMIC UNIT. GO TO P2B

P2B. “Since that appointment have you/has [NAME] given birth?” (DO NOT READ OPTIONS)

• YES GO TO P2C

• NO [STILL PREGNANT OR PREGNANCY ENDED] GO TO P2D

P2C. “Have you already listed the infant/infants that you/that [NAME] gave birth to as part of your household above?” [CONFIRM THAT THE SAME NUMBER OF INFANTS FROM PREGNANCY (P3) ARE ALREADY LISTED IN HOUSEHOLD ENUMERATION CHART] (DO NOT READ OPTIONS)

• YES, WITH [N] BABIES LISTED CAPI WILL SUBTRACT [N] FROM FAMILY ECONOMIC UNIT

• NO, BABY DOES NOT LIVE IN UNIT/DIED/ETC GO TO P2D

P2D. Was anyone else pregnant on CERT_DATE? REPEAT P4-P4D AS NEEDED UNTIL P2D=NO.

• YES GO TO P2

• NO GO TO CONFIRMATION OF SIZE OF FAMILY EONOMIC UNIT

CONFIRMATION OF SIZE OF FAMILY ECONOMIC UNIT (EU_SIZE)

CAPI WILL CALCULATE SURVEY_EU_SIZE AND COMPARE TO FAMILY (EU) SIZE FROM WIC RECORDS (WIC_EU_SIZE).

• IF CERT_CAT= PREGNANT, EU_SIZE INCREMENTED BASED ON Q1P1 SERIES OF QUESTIONS

• IF Q4=18 (CHILD IN TEMP CARE) AND STATE EXCLUDES THESE CHILDREN FROM EU, CHILD WILL BE EXCLUDED FROM PARTICIPANT’S EU

• IF Q4=19 (FOSTER CHILD), THE INDIVIDUAL IS EXCLUDED FROM PARTICIPANT’S EU

• IF Q6=2, THE INDIVIDUAL IS EXCLUDED FROM THE PARTICIPANT’S EU.

IF SURVEY_EU_SIZE = WIC_EU_SIZE, CAPI WILL SKIP TO ADJUNCTIVE/AUTOMATIC ELIGIBILITY.

IF SURVEY_EU_SIZE < WIC_EU_SIZE, CAPI WILL PROMPT:

• “My records show that when you applied for WIC, you had [#IN_FAMILY] people in your family, which is more than we listed today. Have we left someone off the list? Or is there someone on our list who should be counted as part of your main family unit but was not?”

• REVIEW LIST, ADD NAMES/EDIT INFO IF NECESSARY. IF LIST CORRECT, CONTINUE.

IF SURVEY_EU_SIZE > WIC_EU_SIZE, CAPI WILL PROMPT:

• “My records show that when you applied for WIC, you had [#IN_FAMILY] people in your family, which is less than we listed today. Can you confirm that everyone on our list today is part of your main family unit?”

• REVIEW LIST, SUBTRACT NAMES/EDIT INFO IF NECESSARY. IF LIST CORRECT, CONTINUE.

ADJUNCTIVE OR AUTOMATIC ELIGIBILITY

Q7. IF ADJ OR AUTO ELIGIBILITY in WIC RECORDS=YES: “My records show that you qualified for WIC because you, or a member of your family, participates in the [ADJ/AUTO PROGRAM NAME]. Can you show me a document to demonstrate participation in that program, such as a certification card, award letter or notice of benefits?”

IF ADJ OR AUTO ELIGIBILITY in WIC RECORDS =NO: “Were you or someone in your family, participating in a benefits program such as Medicaid, SNAP, TANF or [NAME OF STATE PROGRAM(S)] on [CERT_DATE]?”

YES	“Can you show me a document to demonstrate participation in that program, such as the certification card, award letter or notice of benefits?”
WIC LOOKED UP MY NAME IN PROGRAM ENROLLMENT LIST, WEBSITE, OR BY CALLING RELEVANT AGENCY	“Ok, do you have a certification card, award letter or notice of benefits?”
NO	GO TO INCOME SOURCES

PROOF SHOWN	NO PROOF SHOWN (OR WRONG PROOF)	FLAG FOR FOLLOW-UP WITH STATE AGENCY to confirm enrollment in applicable program
NAME OF PROGRAM RECIPIENT	<select name from Q1 list> CHECK THAT NAME MATCHES SOMEONE IN FAMILY EU	IF NAME ON DOCUMENT DOES NOT MATCH PARTICIPANT’S NAME:	If program is SNAP or FDPIR and NAME on document is member of PARTICIPANT’s family (Q6=share like family), then acceptable proof. If program is Medicaid and NAME on document is a pregnant woman or infant and a member of the PARTICIPANT’s family (Q6=shared), then acceptable proof. If program is TANF and NAME on document is a member of PARTICIPANT’s family (Q6=shared), then acceptable proof.
Date of document/card issuance (mm/dd/yyyy)	TYPE IN: mm/dd/yyyy 99 No date PROBE: Do you have anything that shows the dates of your participation?
Date enrollment expires (mm/dd/yyyy)	TYPE IN: mm/dd/yyyy 99 No date PROBE: Do you have anything that shows the expiration date?
Name of issuing agency	TYPE IN: 99 Not evident PROBE: Do you have anything that shows the agency name?
Number on document/card	TYPE IN: 99 No number
Type of document/card shown:
Certification card Award letter EBT transaction receipt or activity statement w/deposit no greater than 30 days prior to CERT_DATE Other:

CAPI WILL GO TO INCOME SOURCES EVEN IF ADJUNCTIVELY/AUTOMATICALLY INCOME ELIGIBLE: [Note for reviewers: NSWP-III research objectives call for estimate of WIC participants’ income, regardless of adjunctive income eligibility status]

INCOME: ALTERNATE INCOME DETERMINATION PROCEDURE (INDIAN TRIBAL ORGANIZATIONS)

IF ITO=YES AND ALTERNATIVE INCOME PROCEDURE =YES, THE “ALTERNATE INCOME DETERMINATION PROCEDURE” APPLIES. OTHERWISE, CAPI SKIPS ALTERNATE PROCEDURE FOR INCOME DETERMINATION

CAPI PERFORMS A LOOKUP AGAINST TABLE OF INCOME ELIGIBILITY GUIDELINES (IEGs) BASED ON SIZE OF FAMILY ECONOMIC UNIT. CAPI DISPLAYS INCOME THRESHOLD [INCOME_MAX].

ID8 “On [CERT_DATE], was your family’s income at or below $[INCOME_MAX]?”

YES	GO TO ID8A
NO	GO TO INCOME SOURCES (Q8a)

INCOME SOURCES

“Now I’m going to ask you about the income received by you and other primary members of your family unit. Your name, address and other information that identifies you or your family will not be included in study reports. The information we collect will be combined with information from other people in this study from across the U.S. We won’t share personal information about you with your local WIC agency, other benefit programs, your landlord, bank, employer, or people in your community. None of your WIC benefits will change as a result of this survey.”

Q8a. At the time of your most recent certification appointment (on or before [CERT_DATE]), [were you /was NAME] unemployed – that is, had you/NAME been working but stopped?

• Yes GO TO Q8b

• No GO TO INCOME SOURCES

Q8b. About how long had you/NAME been unemployed as of CERT_DATE? READ LIST:

• Less than 30 days before CERT_DATE

• 1 month or longer before CERT_DATE

GO TO Q9

Note for reviewers: The next set of questions asks for income sources and amounts during the 30 days prior to the participant’s certification date. Federal WIC regulations (Section 246.7(d)(2)(i)) permit State agencies to instruct local agencies to determine whether the current rate of income or income over the prior 12 months most accurately reflects the family status (with two exceptions described below). Although policy guidance provides some recommendations, this regulation gives local agencies some flexibility to make independent and non-replicable decisions about which timeframe is more accurate. As a result, FIs will first assess family income based on the current rate of income (defined as the 30 days prior to certification date). If preliminary results suggest that the WIC participant should have been deemed ineligible due to income, the FI will re-assess the family’s income using a reference period of at least 30 days that falls sometime within the year prior to CERT_DATE. The FI will first attempt to obtain income documentation for a total of 30 days during the three months prior to CERT_DATE. Given that families may have sparse documentation for income from prior periods, the FI will accept any proof of income that spans a total of 30 days within the past six months. (For income from self-employment, rental income and royalties, FIs will have already requested proof of income over the past 12 months.)

There are two exceptions to the federal regulations granting flexibility regarding the income timeframe: (1) for families with an unemployed person agencies must determine income eligibility based on current rate of income; (2) for families with an instream migrant worker whose Verification of Certification card is expired, agencies must consider the family to be income eligible so long as the income is redetermined once every 12 months. IF WIC PARTICIPANT’S MIGRANT STATUS =YES, LACK OF DOCUMENTATION OF INCOME WILL NOT RESULT IN “INCOME INELIGIBLE” DETERMINATION.

Q9A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ LIST IN COLUMN A. CHECK ONLY IF YES.

Q9B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Wages, salary or fees (excluding military pay)	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date x Once/lump sum Other: ____
INSTRUCTIONS for Wages, salary or fees (excluding military pay): Use one row per income document. If the income period covers less than one month’s pay (less than 28 days total), you will need more than one paystub or documentation of income from wages, salary or fees. Be sure to enter the income period. If the pay period is not stated on a paycheck or pay statement, enter the date the check or was issued and PROBE for the frequency of pay: Does this income cover one week of work, two weeks, half of the month, one month of work, or some other duration? Income documents are listed in order of preference. Preferred documentation types are underlined. Less preferred options are gray and not underlined. Try to obtain a preferred document type. Record the GROSS pay before deductions for taxes, insurance, or any other amounts withheld from the net pay. If Net Pay is the only amount available from any source, record the Net dollar amount and check the box in the Amount column to indicate that the dollar amount reflects net pay.
IF FREQUENCY IS PER TWO WEEKS OR TWICE/MONTH, PROMPT: Do you have another paystub/document showing the amount you received in the weeks just before [just after] the period covered in this one? IF FREQUENCY IS PER WEEK, PROMPT: Do you have other paystubs/documents showing the amount you received in the weeks before [after] this week? PROMPT: Did you have wages, salary or fees from any other job in the month before CERT_DATE?
Wages, salary or fees (additional paystub)	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Wages, salary or fees (additional paystub)	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
 CLICK TO ADD ROW FOR ADDITIONAL Wages, salary or fees

^x Year to Date will appear as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Tips, bonuses, or commissions (POSSIBLE LUMP SUM)	From: mm/dd/yy To: mm/dd/yy	Paystub/earnings statement Employer statement Business records (for commissions) Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Income from self-employment (farm or non-farm) (NET INCOME)	From: mm/dd/yy To: mm/dd/yy	2017 IRS tax return, 1099 Business records Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Rental income (NET INCOME)	From: mm/dd/yy To: mm/dd/yy	Rental agreement, lease, other business records Cancelled rent check 2017 IRS tax return, 1099 Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Royalties (PROMPT FOR ITOs: per capita payments) (NET INCOME) (POSSIBLE LUMP SUM) (POSSIBLE EXCLUSION)	From: mm/dd/yy To: mm/dd/yy	Paystub/earnings statement Deposit on bank statement 2017 IRS tax return, 1099 Business records Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

^x Year to Date will appear as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Unemployment compensation	From: mm/dd/yy To: mm/dd/yy	Benefit letter/letter of determination Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
IF PARTICIPANT/FAMILY MEMBER INDICATES NO INCOME FROM UNEMPLOYMENT COMPENSATION BUT WAS UNEMPLOYED (Q8A), ASK: UE1. “Did you apply for unemployment benefits?” Yes GO TO UE2 No CONTINUE TO NEXT INCOME SOURCE UE2. “Was your application denied or approved?” DO NOT READ LIST Denied/turned down CONTINUE TO NEXT INCOME SOURCE Approved GO TO UE3 Have not heard back/never heard back CONTINUE TO NEXT INCOME SOURCE UE3. “Okay, you were approved to get unemployment, but you have not received any income from unemployment compensation. Can you show me a copy of the approval letter?” Yes RECORD DATE OF LETTER AND AMOUNT OF BENEFITS AWARDED No CONTINUE TO NEXT INCOME SOURCE
Workers compensation	From: mm/dd/yy To: mm/dd/yy	Benefit letter/letter of determination Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Social security benefits	From: mm/dd/yy To: mm/dd/yy	Award letter from SSA Statement of benefits Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

^x Year to Date will appear as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Federal SSI (Supplemental security income)	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
State SSI or State disability insurance	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Public assistance or TANF	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Energy assistance (amount will be excluded, per WIC regulations)	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Possible income exclusions or lump sums (SEE INCOME PROBE QUESTIONS): Vouchers received under the Workforce Investment and Opportunity Act to cover cost of job training or employment such as transportation, uniforms, or child care. Payments to the Confederated Tribes and Bands of certain Indian Tribes listed in WIC regulations Value of SNAP or WIC food instruments issued to family member

^x Year to Date will appear as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Alimony or child support (1st source)	From: mm/dd/yy To: mm/dd/yy	Check or check stub Support agreement Divorce/separation decree Court order Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Alimony or child support (2nd source)	From: mm/dd/yy To: mm/dd/yy	Check or check stub Support agreement Divorce/separation decree Court order Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Any government or private pension, annuity or survivor’s benefits	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Disbursement from an estate or trust	From: mm/dd/yy To: mm/dd/yy	Earnings statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

^x Year to Date will appear as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Interest or dividends	From: mm/dd/yy To: mm/dd/yy	Earnings or dividend statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Withdrawals from a savings or investment account	From: mm/dd/yy To: mm/dd/yy	Withdrawal receipt/slip Earnings statement Withdrawal on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Possible income exclusions or lump sums (SEE INCOME PROBE QUESTIONS): Payments to American Indian Tribes/Tribal members (SEE EXCLUSIONS LIST) The value of payments (subsidies) for the provision of child care services for low-income families The value of any rental assistance (vouchers), lower mortgage rates, loan guarantees to support home ownership by low-income families (see the Cranston-Gonzales National Affordable Housing Act Housing and Community Development Act of 1987

^x Year to Date will appear as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Veteran’s payments	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Possible income exclusions or lump sums (SEE INCOME PROBE QUESTIONS): Any veteran’s compensation to a Vietnam veteran or veteran who served in Korea in 1968 or 1969 who was exposed to the herbicide known as “Agent Orange”
Military pay (EXCLUSIONS APPLY.CAPI TAKES INTERVIEWER TO MILITARY PAY MODULE)	From: mm/dd/yy To: mm/dd/yy	Leave and Earnings Statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Regular contributions from someone not in household	From: mm/dd/yy To: mm/dd/yy	Letter from payer, dated & signed Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Other income sources (SEE INCOME PROBE QUESTIONS)	From: mm/dd/yy To: mm/dd/yy	Earnings statement Benefit/award letter Letter from payer, dated & signed Deposit on bank statement 2017 IRS tax return, W2, 1099 Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Possible income exclusions or lump sums (SEE INCOME PROBE QUESTIONS): Payments received under the Carl D. Perkins Vocational Education Act or Carl D. Perkins Vocational Applied Technology Education Act Amendments of 1990 Student financial assistance under Title IV of Higher Education Act used for tuition fees, books, equipment materials or supplies required of students for the course of study, including Pell Grant, Supplemental Educational Opportunity Grant (SEOG), State Student Incentive Grant, National Direct Student Loan, PLUS, College Work Study Loans

^x Year to Date will appear as an option only if the Alternate Income Reference Period applies.

ZERO INCOME REPORTED

IF PARTICIPANT DID NOT QUALIFY AS ADJUNCTIVELY/AUTOMATICALLY INCOME ELIGIBILITY FOR WIC AND PARTICIPANT’S TOTAL INCOME = $0 AND NO ADULT AGE ≥ 15 YEARS WAS REPORTED TO HAVE SEPARATE FINANCES, CAPI WILL DISPLAY INTRO AND Z1b-Z2; IF ANY ADULT AGE ≥ 15 YEARS WAS REPORTED TO HAVE SEPARATE FINANCES (Q6=2), CAPI WILL DISPLAY ALL ITEMS

INTRO: “If I understand your answers correctly, it looks like you had zero income on [CERT_DATE].

Z1. You said that [NAME] and [NAME] was/were not part of your family group. Was/Were [LIST NAMES WHERE Q6=SEPARATE FINANCES], or was anyone that you haven’t named helping you to pay for living expenses such as rent/mortgage, heat, or food on [CERT_DATE]?

• Yes GO TO Z1a

• No GO TO Z1b

Z1a. “In that case, I need to ask you about [NAME]’s income. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [NAME] have any income from [REPEAT Q9a for NAME FOR EACH TYPE OF INCOME SOURCE]. CAPI WILL PROMPT INTERVIEWER TO CHANGE THE RESPONSE TO Q6 FOR [NAME(S)] TO Q6=1 SO THAT THIS INDIVIDUAL IS COUNTED AS PART OF PARTICIPANT’S FAMILY

Z2. “I’d like to better understand how you were paying for living expenses in [MONTH, YEAR OF CERT_DATE]. Can you tell me if any of the following were true: CHECK ALL THAT APPLY

I had applied for public assistance but did not received payment until after [MONTH, YEAR OF CERT_DATE] (IF NECESSARY: such as Temporary Assistance to Needy Families (sometimes called welfare) or SNAP or Food Stamps).	REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, PUBLIC ASSISTANCE
I had applied for workers compensation but did not received payment until after [MONTH, YEAR OF CERT_DATE]	REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, WORKER’S COMPENSATION
I received some emergency cash from a church, charity, or social services agency or food from a food bank	ENTER AMOUNT IN Q9, OTHER CASH
I skipped one or more rent, mortgage or utility payments
I did some work such as child care, housework, or another service in exchange for reduced rent or food	IN-KIND BENEFITS NOT INCOME
OTHER: “Can you describe how you paid for living expenses then?” TYPE IN RESPONSE: ____	IF ANY INCOME SOURCES RETURN TO Q9
NONE OF THE ABOVE

AFTER Z2 GO TO END OF SURVEY

ALTERNATE INCOME REFERENCE PERIOD

CAPI WILL MAKE A PRELIMINARY DETERMINATION OF INCOME ELIGIBILITY BASED ON MOST RECENT 30 DAYS’ INCOME PRIOR TO CERTIFICATION DATE REVIEWED.

IF PRELIM_INCOME_ELIG=YES, THEN CAPI WILL SKIP TO END OF CERTIFICATION SURVEY.

IF PRELIM_INCOME_ELIG= NO, THEN CAPI WILL DISPLAY THE FOLLOWING ON-SCREEN.

“I need to be sure we’ve come up with the best estimate of your typical income. We just went over your family’s income during the month before your certification appointment at WIC.”

Q10. During that month, did you, or anyone else I’m going to name, have income that was higher than usual?

	YES	NO
Let’s start with you [WIC PARTICIPANT]: was your income during the month before [CERT_DATE] higher than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period higher than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period higher than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period higher than usual?		

FOR EACH FAMILY MEMBER WHERE Q10=YES, COMPUTER WILL LOOP BACK THROUGH THE INCOME SOURCES USING ALTERNATE REFERENCE PERIOD FOR INCOME PROOF:

“It looks like I may have overestimated your family’s typical income.”

10A. “I’d like you now to think back about three months before [CERT_DATE]: So, I’m talking about [MONTH EQUAL TO MONTH OF CERT_DATE‒90 DAYS] to [MONTH EQUAL TO MONTH OF CERT_DATE ‒60 DAYS]. During that time, did [YOU/FAMILY MEMBER WHERE Q10=YES] have any income from [REVIEW EACH SOURCE IN COLUMN A]. IF INCOME REPORTED ASK 10B, IF NO INCOME FROM THAT SOURCE GO TO NEXT INCOME SOURCE.

IF NO DOCUMENTATION FOR 3^RD MONTH BEFORE CERT_DATE, REQUEST DOCUMENTATION FOR 2^ND MONTH BEFORE CERT_DATE;

IF NO DOCUMENTATION FOR 2^ND MONTH BEFORE CERT_DATE, THEN REQUEST DOCUMENTATION FOR 4^TH MONTH BEFORE CERT_DATE.

IF NO DOCUMENTATION 4^TH MONTH BEFORE CERT_DATE, REQUEST DOCUMENTATION FOR 5^TH MONTH BEFORE CERT_DATE.

IF NO DOCUMENTATION FOR 5^TH MONTH BEFORE CERT_DATE, REQUEST DOCUMENTATION FOR 6^TH MONTH BEFORE CERT_DATE. IF NONE, END LOOP [DO NOT REQUEST DOCUMENTATION OLDER THAN 6 MONTHS PRIOR TO CERT_DATE].

10B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

END OF CERTIFICATION SURVEY

IF PARTICIPANT IS ALSO IN THE SAMPLE FOR THE PROGRAM EXPERIENCES SURVEY:

“Ok, that’s the end of the first part. Here is the first $25 gift card. Next, I’d like to ask about your experiences with the WIC program and your satisfaction with various WIC benefits and services. This next part will take about [ESTIMATED BURDEN OF PROGRAM EXPERIENCE SURVEY] minutes. Afterwards, I’ll give you another $25 gift card. [GO TO PROGRAM EXPERIENCES SURVEY]

IF PARTICIPANT IS NOT IN THE SAMPLE FOR THE PROGRAM EXPERIENCES SURVEY:

“Ok, this completes our survey. It was great talking with you, and thank you so much for helping us out. Here is a $25 gift card in appreciation for your time.

SEE BELOW FOR MILITARY PAY MODULE AND INCOME PROBE QUESTIONS MODULE

MILITARY PAY MODULE²

Using the service member’s military Leave and Earnings Statement, enter the information below. Some pay codes will prompt you to ask clarifying questions that will automatically display. Answering the questions will determine the Income Treatment Code in the rightmost column.

Last Name		First Name		MI	Pay Date	Branch	Period Covered
ENTITLEMENTS
A	Type		Amount		Income treatment codes
B	ENTER PAY CODE		$ .
C	ENTER PAY CODE		$ .		EXCLUDE: BAH
D	ENTER PAY CODE		$ .		EXCLUDE: OCONUS COLA
E	ENTER PAY CODE		$ .
F	ENTER PAY CODE		$ .		ANNUALIZE
G	ENTER PAY CODE		$ .
H	ENTER PAY CODE		$ .
I	ENTER PAY CODE		$ .		EXCLUDE: COMBAT PAY
J	ENTER PAY CODE		$ .
K	ENTER PAY CODE		$ .
L	ENTER PAY CODE		$ .
M	ENTER PAY CODE		$ .
N	ENTER PAY CODE		$ .
O	ENTER PAY CODE		$ .
	REMARKS: ENTER any PAY CODES listed in REMARKS		$ .
	TOTAL		$ .		Countable income after exclusions and annualizations =

POSSIBLE LUMP SUM PAYMENT:

“Does [NAME] receive this pay, [PAYCODE], once a year, monthly, or with some other frequency?”

• Once per year

• Quarterly

• Monthly

• OTHER: SPECIFY FREQUENCY OR PAY INTERVAL

IF FREQUENCY IS ONCE/YEAR OR QUARTERLY, THEN THE AMOUNT WILL BE ANNUALIZED. OTHERWISE ALL AMOUNTS ARE ASSUMED MONTHLY

POSSIBLE COMBAT PAY:

SELECT YES OR NO FOR EACH QUESTION

	YES	NO
Does [NAME] receive this pay in addition to the base pay?		
Is this pay the result of deployment to a designated combat zone?		
Does [NAME] only receive this pay while deployed to the combat zone?		

IF YES TO ALL THREE QUESTIONS, THE PAY IS COMBAT PAY (AND WILL BE EXCLUDED FROM TOTAL INCOME)

IF NO, TO ANY QUESTION, THE PAY IS NOT COMBAT PAY AND WILL BE INCLUDED AS INCOME.

Table 3. Military Pay Codes

Code	Type of Pay	Counts as Income unless noted otherwise
AB	Accession bonus	Ask Lump Sum
ACIP	Aviation Career Incentive Pay
ACP	Aviation Continuation Pay
AIP	Assignment Incentive Pay	Ask Combat Pay
ASP	Additional Special Pay
BAH	Basic Allowance for Housing	if State excludes
BAS	Basic Allowance for Subsistence
BAQ	Basic Allowance for Quarters	if State excludes
Base Pay	Base Pay
BCP	Board Certified Pay Special Pay
CCA	Civilian Clothing Allowance	Ask Lump Sum
BRA	Basic Replacement Allowance	Ask Lump Sum
Continuation Pay	Continuation Pay
CCCA	Continuing Civilian Clothing Allowance	Ask Lump Sum
CCRA	Cash Clothing Replacement Allowance	Ask Lump Sum
CEFIP	Career Enlisted Flyer Incentive Pay
CIP	Combat-related Injury & Rehabilitation	Ask Combat Pay
CMA	Clothing Maintenance Allowance or Clothing Allowance
CONUS COLA	Continental U.S. Cost of Living Allowance	Exclude, in-kind benefit
Combat Duty or Combat Zone Pay	Combat Duty or Combat Zone Pay	EXCLUDE
CRA	Clothing Replacement Allowance	Ask Lump Sum
CSP	Career Sea Pay
CSP-P	Career Sea Pay – Premium
CSRB	Critical Skills Retention Bonus	Ask Lump Sum
CVI	Conditional Voluntary Indefinite Status
DLA	Dislocation Allowance	Exclude, in-kind benefit
Dive Pay	Dive Pay	Ask Combat Pay
DSCT Meal	Discount Meal	Exclude, in-kind benefit
FDP	Foreign Duty Pay	Ask Combat Pay
FLPP	Foreign Language Proficiency Pay	Ask Combat Pay
Flight or Fly Pay	Flight or Fly Pay	Ask Combat Pay
FSA	Family Separation Allowance	Ask Combat Pay
FSH	Family Separation Housing	Exclude, in-kind benefit
FSSA	Family Subsistence Supplemental Allowance	EXCLUDE
HALO	High Altitude/Low Altitude	Ask Combat Pay
HDIP	Hazardous Duty Incentive Pay	Ask Combat Pay
HDP – Involuntary Extension	Hardship Duty Pay – Involuntary Extension	Ask Combat Pay
HDP – L	Hardship Duty Pay - Location	Ask Combat Pay
HDP – M	Hardship Duty Pay – Mission	Ask Combat Pay
HFP/IDP	Hostile Fire/Imminent Danger Pay	Ask Combat Pay
HFP-L	Hostile Fire Pay - Location	Ask Combat Pay
HZD	Hazardous Duty Pay	Ask Combat Pay
ICCA	Initial Civilian Clothing Allowance	Ask Lump Sum
IDP	Imminent Danger Pay Note: Can also mean Independent Duty Corpsman	Ask Combat Pay
ISP	Incentive Special Pay
Jump Pay	Jump Pay	Ask Combat Pay
LQA	Living Quarters Allowance	Exclude, in-kind benefit
Maternity Clothing Allowance	Maternity Clothing Allowance	Ask Lump Sum
MIHA – Miscellaneous	Moving Housing Allowance - Miscellaneous	Exclude, in-kind benefit
MIHA – Rent	Moving Housing Allowance – Rent	Exclude, in-kind benefit
MIHA – Security	Moving Housing Allowance - Security	Exclude, in-kind benefit
MRB	Multiyear Retention Bonus
MSP	Multiyear Special Pay
NIB	Nuclear Career Annual Incentive Bonus
NPAB	Nuclear Power Accession Bonus	Ask Lump Sum
Nuclear – Continuation Pay	Nuclear – Continuation Pay
OEP	Overseas Extension Pay
OHA	Overseas Housing Allowance	Exclude, in-kind benefit
OCONUS COLA	Overseas Continental United States Cost of Living Allowance	if State excludes
OTEIP	Army Overseas Tour Extension Incentive Pay
OVERSEAS COLA	Overseas Cost of Living Allowance	Exclude, in-kind benefit
Overseas Extension Pay	Overseas Extension Pay
PCCA	Partial Civilian Clothing Allowance	Ask Lump Sum
RBMA	Reserve Basic Maintenance Allowance
SBP	Military Survivor Benefits Plan
SAVE PAY	Save pay Note: This can represent many types of pay. Ask questions to determine what the pay is for to see if it counts. Often refers to difference in pay due to accepting a new appointment between new and old pay rates. Likely to be a lump sum.	Caution: ask if lump sum
SDAP	Special Duty Assignment Pay	Ask Combat Pay
SDIP	Submarine Duty Incentive Pay	Ask Combat Pay
Sea Pay	Sea Pay	Ask Combat Pay
SEA	Subsistence Expense Allowance
SEB	Selective Enlistment Bonus	Ask Lump Sum
SepRats	Separation Rations
SMA	Standard or Separate Maintenance Allowance
Special Duty Pay	Special Duty Pay	Ask Combat Pay
Specialty Pay	Specialty Pay	Ask Combat Pay
SPO	Split Payment Option Note: This option allows the person to take an amount from the base pay and put it into the ship ATM for personal use while on board. Base WIC income eligibility on the gross amount before the split allocation. Don’t count the amount sent to the ship account twice.	Caution
SR	Separation Rations
SRA	Standard Replacement Allowance	Ask Lump Sum
SRB	Selective Reenlistment Bonus	Ask Lump Sum
Standard Initial Clothing Allowance	Standard Initial Clothing Allowance	Ask Lump Sum
Submarine Pay	Submarine Pay
SUPP CMA	Enlisted Supplemental Clothing Allowance	Ask Lump Sum
TDYCCA	Temporary Duty Civilian Clothing Allowance	Ask Lump Sum
TLE CONUS	Temporary Lodging Expense in US	Exclude, in-kind benefit
TLA	Temporary Living Allowance	Exclude, in-kind benefit
TLA OCONUS	Temporary Lodging Allowance Outside US	Exclude, in-kind benefit
TQSA	Temporary Quarters Subsistence Allowance
VI	Voluntary Indefinite Status
VBSS Duty	Maritime Visit, Board, Search & Seizure Duty
VSP	Variable Special Pay

INCOME PROBE QUESTIONS (POSSIBLE EXCLUSIONS OR LUMP SUMS)

AT ANY TIME WHILE ASKING PARTICIPANT ABOUT INCOME SOURCES (Q9), THE INTERVIEWER MAY BRING UP A LIST OF THE FOLLOWING POTENTIAL LUMP SUM OR INCOME EXCLUSION QUESTIONS:

If participant is a member of an American Indian Tribe and:	ASK/DO
Reports income from the government or Tribe	“Did you receive this income as part of a settlement or agreement between the U.S. government and an American Indian tribe or Nation?” EXCLUDE ANY SUCH INCOME3 “Is this income a ‘per cap’ or per capita payment from a business operated by an American Indian tribe or Nation to which you belong?” ENTER NET AMOUNT UNDER ROYALTIES. ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED

If participant or income document refers to:	ASK/DO
Section 8, housing voucher, rental assistance	“Is this a voucher to help you afford housing or rent?” ANY AMOUNT SHOWN ON A HOUSING CHOICE VOUCHER IS NOT COUNTED AS INCOME. DO NOT ENTER AS AN INCOME SOURCE.4
Child care or day care voucher, child care or day care assistance	EXCLUDE ANY REPORTED PUBLIC ASSISTANCE OR SUBSIDY FOR DAY CARE OR CHILD CARE COSTS5
Food Stamps, Free or Reduced Price Lunch or Breakfast for child in public school, WIC food instruments provided to other WIC participants in family	EXCLUDE ANY REPORTED PUBLIC ASSISTANCE WITH MEALS OR FOOD, INCLUDING ANY REPORT OF FREE MEALS A CHILD RECEIVES AT SCHOOL, FOOD INSTRUMENTS RECEIVED BY ANY FAMILY MEMBER FROM SNAP, FDPIR, OR WIC.6
Job assistance, employment training, Employment Services Program, Job Corps, Youth Build, job training, American Job Center, Workforce Investment, Employment Training, Career Pathway	“Was this income to reimburse you for transportation, child care costs or other expenses so that you could take part in job training, get a GED or take classes that will prepare you for employment?” EXCLUDE REIMBURSEMENTS FOR THESE EXPENSES 7
Volunteer, AmeriCorps, VISTA	“Was this income you received as a volunteer for AmeriCorps, AmeriCorps VISTA or AmeriCorps National Civilian Community Corps (NCCC)?”8
Bonus/commissions	ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED
Royalties	ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED
Any mention of emergency assistance due to a hurricane, tornado, storm, earthquake, volcano, landslide, mudslide, snowstorm, flood, forest fire	“Did you receive [this] assistance because of a major disaster such as a hurricane, tornado, storm or similar natural event that was declared a federal disaster?” FEMA maintains a list of federal disasters each year: https://www.fema.gov/disasters/grid/year/2015. EXCLUDE ANY ASSISTANCE DUE TO FEDERAL DISASTER FROM INCOME SOURCES9
Any mention of loss of property due to flood/hurricane	“Did this income come from FEMA or the National Flood Insurance Program after filing a claim for flood damage to your home? EXCLUDE ANY INCOME DUE TO APPROVED FLOOD DAMAGE CLAIM10
Veteran’s or VA payment, VA disability	“Did you/NAME receive payment because you were exposed to Agent Orange while serving in Vietnam or Korea?” EXCLUDE ANY AMOUNT DUE TO EXPOSURE TO AGENT ORANGE. INCLUDE ALL OTHER VETERAN’S PAYMENTS11
Loan, Student loan	“Is this income part of a loan that you must repay?” EXCLUDE ANY LOAN AMOUNT FROM INCOME SOURCES unless the loan is an amount to which the participant has constant access (e.g., regular contributions from someone not in the household)12

Certification Survey for WIC participants: Version B (Infant/Child)

This is Version B of the NSWP-III Certification Survey. Version B is used when the participant is an infant or child. The survey respondent for Version B is the adult applicant who sought WIC certification for the infant or child. Version A (included separately) is used when the sampled participant is a pregnant, breastfeeding or postpartum, non-breastfeeding woman.

Instructions for Reviewers

The Certification Survey will be administered by trained Field Interviewers (FIs). After the pretest results the survey will be implemented in a Computer Assisted Personal Interview (CAPI) format programmed onto study laptops.. This paper version approximates the layout of the CAPI questionnaire and includes notes indicating how the CAPI system will automatically route the interviewer to the appropriate questions or data entry forms, or performs specified calculations (these notes appear in the paper version in RED, CAPITALIZED text but will not appear in the CAPI version). In addition, the CAPI version will be programmed to pre-populate certain data about each participant sampled for the Certification Survey; these data elements appear in Table 2 on the next page.

The NSWP-III version of the Certification Survey is adapted from the version used in NSWP-II. This is motivated by an effort to minimize differences in data collection to allow meaningful comparison of the estimates of improper payment errors between the two studies. The survey is organized into the following modules:

Table 1: Certification Survey Modules
Name	Purpose
Identity	Document proof of identity
Residency	Document proof of residency
Category	For Infant or Child participants, confirm participant category
Income	Determine the size of the participant’s family economic unit (SURVEY_EU_SIZE); Collect documentation of income sources
End survey	Thank participant and conclude survey
Military Pay Module	Module to assist in determining income and exclusions for military service members
Income Probe Module	Questions in the event one or more reported income sources may be subject to WIC income exclusion regulations

Typically, FIs will administer the five numbered modules in order, but FIs may navigate between modules as needed during survey administration. The two final modules are supplementary, included for use by FIs if needed. The Military Pay Module assists FIs in correctly including or excluding income from pre-specified pay codes (e.g., combat pay codes and FSSA are excluded) or querying if a military pay “allowance” is a lump sum paid other than monthly. The Income Probe Module includes questions FIs will ask if a respondent reports income that may come from a source that must be excluded per federal WIC regulations.

Text that FIs read aloud (questions, response options where indicated) appear in regular text, while on-screen instructions to FIs appear in CAPITALIZED TEXT.

Table 2. Data Pre-Populated into the Computer-Assisted Personal Interview (CAPI) system for each Participant in the Sample
Variable	Description
PARTICIPANT	Name of certified WIC participant (Last, First, Middle)
DOB	Date of birth of infant or child participant
APPLICANT	Name of Certification Survey applicant if PARTICIPANT is infant or child
ADDRESS	Participant’s address (number, street, apartment number, city, state, zip code)
STATE	Participant listed in this State’s WIC participant data
STATE_ID	State WIC Agency identifier
LOCAL_ID	Local WIC Agency identifier
CLINIC_ID	Local clinic identifier
ITO	Yes/No, Participant is from an ITO or an LWA run by an Indian organization or Indian Health Service
CERT_CAT	Participant’s category (as assigned by WIC) P=pregnant; B=breastfeeding; N=not breastfeeding postpartum; INF=infant; C=child
CERT_DATE	Start date of most recent certification period
CERT_EXPIRES	End date of certification period
CERT_PERIOD	Number of days of most recent certification period (1 to 365)
	30 days 60 days 90 days 120 days	1 month 2 months 3 months 4 months	150 days 180 days 210 days 240 days	5 months 6 months 7 months 8 months	270 days 300 days 330 days 360+ days	9 months 10 months 11 months 12 months
ADJUNCTIVE	Yes/No, Participant was certified as adjunctively income eligible by WIC
AUTOMATIC	Yes/No, Participant was certified as automatically income eligible by WIC
ADJC_PRG	Name of program that made participant adjunctively eligible
AUTO_PRG	Name of program that made participant automatically eligible
MIGRANT	Yes/No, Participant is a migrant worker
EU_SIZE	Economic Unit size -- number of persons in participant’s family Economic Unit
EU_ADULT	Number of persons aged 15 years or older in participant’s EU
EU_CHILD	Number of persons younger than 15 years in participant’s EU
PREG_NUM	Number of expected live births: if SINGLETON, PREG_NUM=1; if TWINS, PREG_NUM=2; etc.

Certification Survey for WIC participants (Version B: Infant or Child)

Version B: Infant or Child WIC Participant

THE FOLLOWING INFORMATION WILL BE AVAILABLE TO INTERVIEWER WHILE ADMINISTERING THE SURVEY:

PARTICIPANT Last­_Name				PARTICIPANT First_Name		Participant Category		Certification Date (CERT_DATE)	Certification Period	Prior WIC Participant?	Migrant?
Doe				Jane		P/B/N/INF/C		mm/dd/yy	xx days/months	Yes/No	Yes/No
CAREGIVER Last­_Name				CAREGIVER First_Name
Doe				Janelle
State:	MN		City:	Anytown		ZIP:	12345	Street:	100 Main Street
Reciprocity?			Yes/No	Participant of WIC in which State:		ST	Participant’s LWA:		Local Agency where participant receives WIC benefits, services
Family (EU) Size			#	Adjunct/Auto Elig?		Y/N	Adjunctive program name:
ITO?			Yes/No	Use alternate income procedure?			Yes/No
IF PARTICIPANT IN ITO OR SERVED BY ITO OR LIVES IN INDIAN VILLAGE:
Village						Reservation or Sovereign Nation
State:		City:			Anytown	ZIP:		PO Box:

INTRO: Hi. Thanks for agreeing to do this survey. We will keep your answers private to the extent allowed by law. None of the information you share with me will cause your WIC benefits to change. The purpose of the survey is to help get a better idea of who participates in the program and their family’s circumstances. After we finish, I will give you a $25 gift card to thank you for your participation. Before we start, we need to review this form together. It tells you about your rights as a study participant. It tells you how we will protect your privacy and how we will use your answers.

READ INFORMED CONSENT STATEMENT AND GET SIGNED CONSENT BEFORE PROCEEDING.

Field Interviewer confirmation at end of survey:

I met with participant at the following address on the date below: MAKE ANY CORRECTIONS IN THE ROW BELOW								INITIALS
State:	MN	City:	Anytown	ZIP	12345	Street	100 MAIN STREET
						Date	mm/dd/yy

• Location was a residential address

• Location was a non-residential address (e.g., library, business, community center). PROVIDE NAME OF LOCATION:

IDENTITY

2. The first thing we need is some identification for [NAME of INFANT/CHILD WIC PARTICIPANT]. [IF PARTICIPANT HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF ID FROM LIST.]

HAS IDENTIFICATION FOR INFANT/CHILD?

 YES GO TO 1A

 NO IF PRIOR_WIC_PARTICIPANT=YES, GO TO 1B. IF PRIOR_WIC_PARTICIPANT=NO, GO TO 1C

1A. IF NAME MATCHES WIC RECORD CHECK OFF ID SHOWN AND GO TO NEXT MODULE

IF ID NAME DIFFERS: “The name on this ID doesn’t match my records. Can you show me a form of ID [another form of ID] that has your child’s name?”

Identification proofs [CHECK AT LEAST ONE]				(INFANT or CHILD ID		CAREGIVER ID (if no ID for infant/child)	ID shown during survey	ID shown at WIC
Birth certificate w/infant/child’s name								
Hospital or immunization record, hospital ID bracelet w/infant/child’s name								
U.S. or foreign passport w/photo and infant/child’s name								
Social Security or Green card for infant/child (or other Immigration document with name)								
Letter from government agency (including WIC) w/ infant/child’s name								
WIC ID Card or WIC folder (PRIOR WIC PARTICIPANTS only) with infant/child name (EBT cards are NOT valid proof of identity)								
School, military, bus pass ID (or work ID for adult) w/photo & name								
PARENT/GUARDIAN ONLY: Driver’s license w/photo & name								
State- or Tribal- issued license of ID w/photo & name								
OTHER: specify ID shown AT WIC: DURING SURVEY:								
FI Notes					FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

1B. (PRIOR_WIC_PARTICIPANT = YES): “Ok, the records I have show that your child most recently certified for WIC on CERT_DATE, and that he/she was receiving WIC benefits before that. Can you show me a WIC ID card, or something the WIC office gave you with your child’s name and address?” [TRANSFER/VERIFICATION OF CERTIFICATION NOT ACCEPTABLE PROOF OF IDENTITY]

• WIC FOLDER GO TO 1A

• OTHER DOCUMENT FROM WIC WITH NAME/ADDRESS GO TO 1A

• NEITHER GO TO 1C

1C. (PRIOR_WIC_PARTICIPANT = NO) OR 1B=NEITHER: “Ok, do you have any ID for yourself?”

IF YES, SELECT APPROPRIATE ROW FOR TYPE OF APPLICANT ID IN QUESTION 1A. IF NO, GO TO 1D.

1D. “Was your ID, or records having to do with your child’s recently stolen, did you recently lose your ID or your child’s records? Have you and your child recently been homeless, or experienced a fire, flood, hurricane, tornado, or similar event?”

 STOLEN/LOST GO TO 1E

 HOMELESS GO TO 1E

 DISASTER VICTIM GO TO 1E

 {State specific reason providing ID = unreasonable burden} GO TO 1E

 NONE OF THE ABOVE GO TO 1E

1E. “At your recent WIC certification appointment on or before CERT_DATE, did you show any identification for [NAME OF INFANT/CHILD WIC PARTICIPANT] then?” (IF YES: Do you recall what type of ID you showed?) CHECK BOTH WHETHER ID FOR CHILD AND FOR SELF SHOWN

 SHOWED ID FOR CHILD AND RECALLS TYPE CHECK OFF ID SHOWN AT WIC IN IDENTIFICATION PROOF TABLE AND GO TO NEXT MODULE

GO TO NEXT MODULE.

30-day CERT_PERIOD and NO ID SHOWN = NO ERROR.

Else, IF STATE REQUIRES ID FOR INFANT/CHILD AND NO INFANT/CHILD ID SHOWN = ID ERROR.

IF STATE ACCEPTS ID OF APPLICANT AND NO ID SHOWN = ID ERROR.

 SHOWED ID FOR SELF AND RECALLS TYPE

 SHOWED ID FOR CHILD BUT NO RECALL OF TYPE

 SHOWED ID FOR SELF BUT NO RECALL OF TYPE

 DID NOT SHOW ID FOR EITHER

 DO NOT RECALL

RESIDENCY: GEOGRAPHIC STATE

IF PARTICIPANT FROM ITO OR LIVES IN REMOTE INDIAN VILLAGE OR PUEBLO THEN CAPI WILL SKIP TO “ALTERNATE PROOF OF RESIDENCY.” ELSE CONTINUE WITH RESIDENCY: GEOGRAPHIC STATE PROCEDURE.

IF IDENTIFICATION SHOWN AS PROOF OF IDENTITY HAS ADDRESS AND IS AN ACCEPTED PROOF OF RESIDENCY, MARK OFF THE TYPE OF RESIDENCY PROOF IN TABLE BELOW AND SKIP TO INCOME ELIGIBILITY MODULE. OTHERWISE GO TO QUESTION 2.

2. “Next, I need some kind of proof that you live here. Do you have a utility bill, lease, or letter addressed to you?” MAIL MUST HAVE RESIDENTIAL ADDRESS. P.O. BOX DOES NOT = PROOF OF RESIDENCY. RURAL ROUTE BOX NUMBER IS ACCEPTABLE RESIDENTIAL ADDRESS.

HAS PROOF OF RESIDENCY?

YES GO TO 2A

NO IF PRIOR_WIC_PARTICIPANT=YES, GO TO 2B. IF PRIOR_WIC_PARTICIPANT=NO AND MIGRANT=YES, GO TO 2C(i); IF PRIOR_WIC_PARTICIPANT=NO AND MIGRANT=NO, GO TO 2C(ii)

2A. IF NAME AND ALL ADDRESS FIELDS MATCH WIC RECORD FOR APPLICANT OR INFANT/CHILD, CHECK OFF RESIDENCY PROOF AND GO TO NEXT MODULE.

IF ADDRESS FIELDS MATCH AND NAME DIFFERS, GO TO 2D.

IF ANY ADDRESS FIELD DIFFERS, GO TO 2E.

Residency proofs [CHECK AT LEAST ONE]			Shown during survey	Shown at WIC
Same as ID shown (IDENTITY MODULE). Includes name AND residential address				
Driver’s license with name & address				
State- or Tribal- issued license or ID w/name & address				
Utility bill, rent/mortgage receipt, or lease w/name & address				
Letter from government agency (including WIC) w/name & address				
Postmarked mail from reliable third party w/name & address				
OTHER: specify PROOF shown AT WIC: DURING SURVEY:				
FI Notes	

2B. (PRIOR_WIC = YES): “Ok, the records I have show that your child most recently certified for WIC on CERT_DATE, and that he/she was receiving WIC benefits before that. Can you show me a WIC folder, or something the WIC office gave you with you or your child’s name and address?”

• WIC FOLDER GO TO 2A

• OTHER DOCUMENT FROM WIC WITH NAME/ADDRESS GO TO 2A

• NEITHER GO TO 2C

2C(i). (PRIOR_WIC = NO AND MIGRANT = YES): “Do you, or does anyone in your household, work on farms and move from place to place as the season changes?” IF NECESSARY: “WIC agencies have special rules for families include a migrant farmworker who moves around the country depending on where there is work based on the growing season.”

• YES (MIGRANT FARMWORKER) GO TO 2F

• NO GO TO 2C(ii)

2C(ii). (PRIOR _WIC = NO OR 2B=NEITHER OR 2E=NO): “Did you recently lose documents with your address or were they stolen? Have you and your child recently been homeless, or recently experienced a fire, flood, hurricane, tornado, or similar event?”

 STOLEN/LOST GO TO 2F

 HOMELESS GO TO 2F

 DISASTER VICTIM GO TO 2F

 {State specific reasons providing proof = unreasonable burden} GO TO 2F

 NONE OF THE ABOVE GO TO 2F

2D. (ADDRESS MATCHES BUT NAME DIFFERS): “This has an address, but neither your name or your child’s name. Do you have something with your name and address (or your child’s name and address)?” READ LIST IN 2A FOR EXAMPLES OF OTHER TYPES OF DOCUMENTS FOR RESIDENCY PROOF.

2E. (ADDRESS DIFFERS OR NAME AND ADDRESS DIFFER): “Ok, the [name and] address on this document doesn’t match my records.

Have you moved since CERT_DATE? Just as a reminder, WIC won’t know any personal information you share with me, including whether or not your address has changed.”

• YES (RECENTLY MOVED) ENTER INFO BELOW AND GO TO 2F

• NO (DID NOT RECENTLY MOVE) REVERSE TO 2C

State:

ZIP:

ADDRESS IS A STREET ADDRESS (Not PO Box)?

 Yes  No

2F. “At your recent WIC certification appointment, did you show anything with your child’s or your name and address then?” (IF YES: “Do you recall what type of document you showed?”)

 SHOWED PROOF AND RECALLS TYPE CHECK OFF PROOF SHOWN AT WIC ON RESIDENCY PROOF TABLE AND GO TO NEXT MODULE

GO TO NEXT MODULE.

30-day CERT_PERIOD and NO PROOF SHOWN = NO ERROR.

Else, NO PROOF SHOWN = RESIDENCE PROOF ERROR

 SHOWED PROOF BUT NO RECALL OF TYPE

 DID NOT SHOW PROOF

 DO NOT RECALL

RESIDENCY: ALTERNATE PROCEDURE (ITO/REMOTE INDIAN VILLAGE/PUEBLO)

ALTERNATE PROCEDURE APPLIES ONLY IF PARTICIPANT FROM ITO OR LIVES IN REMOTE INDIAN VILLAGE OR PUEBLO “ALTERNATE PROOF OF RESIDENCY PROCEDURE” APPLIES. ELSE USE RESIDENCY: GEOGRAPHIC STATES

ALTERNATIVE RESIDENCY PROCEDURE: GET VILLAGE NAME AND MAILING ADDRESS.

IF WIC RECORDS SHOW A RESIDENTIAL STREET ADDRESS (NOT A PO BOX), GO TO ALT 2A.

IF WIC RECORDS SHOW A PO BOX AND DO NOT SHOW VILLAGE, GO TO ALT 2B.

IF WIC RECORDS DO NOT SHOW A PO BOX AND SHOW A VILLAGE, GO TO ALT 2B.

IF WIC RECORDS SHOW A PO BOX AND SHOW A VILLAGE, GO TO ALT 2D.

ALT 2A. “At your most recent visit to the WIC office, did you have to show a document with you and your child’s home address?”

YES “What type of document did you show?” GO TO RESIDENCY: GEOGRAPHIC STATE AND ENTER PROOF SHOWN AT WIC

NO GO TO ALT 2B

ALT 2B.	“What is the name of the town, village or pueblo where you live?”
Village from WIC records		Matches WIC records?
Village		Yes	No

IF VILLAGE NAME MATCHES WIC RECORDS, GO TO ALT 2D. IF NO VILLAGE IN WIC RECORDS OR PARTICIPANT RELUCTANT TO GIVE VILLAGE NAME GO TO ALT 2D. IF VILLAGE NAME GIVEN DOESN’T MATCH GO TO ALT 2C.

ALT 2C

(i) “My records say that you were living in [VILLAGE]. Is there another name for the place you live?”

• YES (RECORD NAME) GO TO ALT 2D

• NO GO TO ALT 2C(ii)

(ii) “Did you recently move? Just as a reminder, WIC won’t know any personal information you share with me, including whether or not where you live has changed.”

• YES (RECENTLY MOVED) GO TO ALT 2D

• NO (DID NOT RECENTLY MOVE) GO TO ALT 2D

ALT 2D. MAILING ADDRESS: “What is your current mailing address?”

Mailing address from WIC records
P.O. Box or Street Address	P.O. Box NN	State	MN	ZIP	ZZZZZ
City	Anywhere
IF MAILING ADDRESS DIFFERENT FROM WIC RECORDS
Gave mailing address	 Yes  No
City		State		ZIP

IF MAILING ADDRESS MATCHES WIC RECORDS, GO TO NEXT MODULE. IF NO MAILING ADDRESS IN WIC RECORDS OR RELUCTANT TO GIVE MAILING ADDRESS, GO TO NEXT MODULE.

IF MAILING ADDRESS GIVEN DOESN’T MATCH WIC RECORDS, GO TO ALT 2E.

ALT 2E. (CHANGE OF MAILING ADDRESS) “Did you recently change your mailing address? Remember, WIC won’t know any personal information you share with me, including any change in your mailing address.”

• YES GO TO NEXT MODULE

• NO GO TO NEXT MODULE

FI Notes



FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

PARTICIPANT CATEGORY

“Next, I’d like to confirm your child’s date of birth. When was [PARTICIPANT] born?”

ENTER DOB: mm/dd/yyyy. READ THE ENTIRE BIRTH DATE BACK TO APPLICANT TO CONFIRM ENTRY.

CAPI WILL CALCULATE THE INFANT OR CHILD’S AGE AS OF CERT_DATE TO DETERMINE WHETHER THE PARTICIPANT CATEGORY IS CORRECT OR ERRONEOUS.

IF THE PARTICIPANT’S CATEGORY = INFANT, THEN THE INFANT CATEGORY IS CORRECT IF A OR B IS TRUE.

1. THE INFANT MUST BE ≤ 12 MONTHS ON CERT_DATE, OR

2. THE INFANT’S CERT_DATE FALLS ON OR BETWEEN THE BIRTHDATE + 1 YEAR AND THE LAST DAY OF THE MONTH IN WHICH THE INFANT REACHES 1 YEAR OF AGE +. EXAMPLE:

John Doe was born on April 2, 2016. John Doe has never received WIC before. The most recent certification date was April 10, 2017 and he was certified as an infant, even though he was 12 months, 8 days old. The last day of the month equal to John Doe’s DOB + 1 year is April 30, 2017. CAPI would determine that the participant category was correct. (Although unusual for a WIC agency to certify John Doe as an infant for the remainder of the month, it is technically possible and consistent with WIC regulations.)

IF THE PARTICIPANT’S CATEGORY = CHILD, THEN THE CHILD CATEGORY IS CORRECT IF A OR B OR C IS TRUE:

1. THE CHILD MUST BE ≤ 60 MONTHS AND > 12 ON CERT_DATE, OR

2. THE CHILD’S CERT_DATE FALLS ON OR BETWEEN THE BIRTHDATE + 60 MONTHS AND THE LAST DAY OF THE MONTH IN WHICH THE CHILD REACHES 60 MONTHS OF AGE, OR

3. (NOTE THAT WIC REGULATIONS (246.7(g)(3)) ALLOW LOCALAGENCIES TO SHORTEN OR EXTEND A CURRENT CERTIFICATION PERIOD FOR AN INFANT OR CHILD UP TO 30 DAYS IF THERE IS DIFFICULTY SCHEDULING A CERTIFICATION APPOINTMENT): THE CHILD IS < 12 MONTHS AND THE CERT_DATE FALLS ON OR BETWEEN THE LAST DAY OF THE MONTH IN WHICH THE INFANT TURNS 11 MONTHS OF AGE AND THE BIRTHDATE + 1 YEAR. EXAMPLE:

Jane Doe was born on 12-25-16 and is certified as an infant through 12-31-2017. However, Jane’s mother is having difficulty scheduling a certification appointment for Jane. Her local WIC agency suggests that she come to a certification appointment for Jane on 12-02-17. On that date, the agency certifies Jane as a CHILD even though Jane is 11 months, 7 days old. The agency has discretion to shorten the infant certification period by up to 30 days (i.e., to December 1, 2017) and extend the child certification by this same amount. Jane is less than 12 months of age on her certification date but the certification date is between the last day of the month in which she turns 11 months (November 30) and her first birthday. CAPI would determine that the participant category is correct – no error.

INCOME ELIGIBILITY

HOUSEHOLD ENUMERATION

“Next, I’m going to ask you to tell me the names of all the people who were living or staying with [NAME OF SAMPLED INFANT/CHILD PARTICIPANT] in [MONTH OF CERT_DATE] and whether they are related or not. I’ll type the names so that I can follow up with some questions. Be sure to include yourself, but please list only people who were living with [SAMPLED INFANT/CHILD] in [MONTH OF CERT_DATE]..”

RECORD EACH NAME IN THE LIST BELOW. ENTER FIRST NAME ONLY

1. PROBE FOR ADDITIONAL PERSONS: Anyone else?

2. Is [NAME] male or female?

3. How old is [NAME]?

4. What is [NAME]’s relationship to [NAME OF INFANT/CHILD]?

IF RELATIONSHIP IN Q4 = 20 (FOSTER PARENT), ASK Q4(FOSTER)

ASK Q4(FOSTER): “Just to confirm, is [NAME OF SAMPLED INFANT/CHILD PARTICIPANT] your/[NAME]’s foster child?”

• YES CAPI WILL ENUMERATE SAMPLED FOSTER INFANT/CHILD AS FAMILY ECONOMIC UNIT OF 1.

GO TO “ADJUNCTIVE OR AUTOMATIC ELIGIBILITY” SECTION

• NO REPEAT Q4 TO DETERMINE RELATIONSHIP, THEN CONTINUE WITH HOUSEHOLD ENUMERATION

Q1	Q2	Q3	Q4	Relationship Codes
NAME	GENDER 1=male 2=female	AGE in years	RELATIONSHIP	6=parent 7=step-parent 8=legal guardian 9=brother/sister 10=grandparent	11=uncle/aunt 12=cousin 13=nephew/niece 14=parent in-law 15=brother-in-law/sister-in-law 16=other relative 17=non-relative 18=child in temporary care 19=foster child 20=foster parent 21=infant/child WIC participant
SAMPLED INFANT/CHILD			21

ANYONE ELSE? 

FI MAY CLICK FOR ADDITIONAL ROWS AT ANY TIME DURING THE INTERVIEW. CAPI will add additional rows one at a time, up to 20 persons.

IF ANY Q4= 19 [HOUSEHOLD INCLUDES A FOSTER CHILD WHO SHOULD BE EXCLUDED FROM SAMPLED ECONOMIC UNIT], DISPLAY Q4FOSTER(ii): “When you applied for WIC, did you tell WIC that [NAME OF HOUSEHOLD MEMBER where Q4=19] is a foster child?  YES NO

FAMILY MEMBERS TEMPORARILY AWAY

Q1. “Other than people already listed, is there anyone who typically lives here but who was temporarily away in [MONTH OF CERT_DATE]? (IF NECESSARY, PROBE: For example, this could be a military service member on active deployment, someone who is in the hospital, in jail or serving time in prison, a child away at school, or a child who lives part-time with each parent. Is there anyone who typically lives here but who was temporarily away?”

• Yes ADD MEMBERS TEMPORARILY AWAY

• No GO TO CHILDREN IN TEMPORARY CARE

1. LIST NAME OF EACH PERSON TEMPORARILY AWAY

2. “Is [NAME] male or female?”

3. “How old is [NAME]?”

4. “What is [NAME]’s relationship to [NAME OF INFANT/CHILD]?”

Q4B. “Can you tell me the main reason this person was temporarily away?” DO NOT READ LIST. PROBE FROM LIST IF NECESSARY.

1=MILITARY MEMBER ON ACTIVE DEPLOYMENT

2=IN THE HOSPITAL/REHAB OR TREATMENT CENTER/HALFWAY HOUSE

3=LIVING AWAY AT SCHOOL (BOARDING SCHOOL, COLLEGE)

4=CHILD LIVES PART-TIME IN HOUSEHOLD

5=OTHER, SPECIFY [DO NOT LIST ANY PERSON WHO WAS IN JAIL/PRISON IN MONTH OF CERT_DATE]

Members temporarily away
Q1A	Q2A	Q3A	Q4A	Relationship Codes		Q4B	Q4C
NAME	GENDER	AGE	RELATIONSHIP	1=spouse 2=partner 3=child 4=step-child 5=adopted child 6=parent 7=step-parent 8=legal guardian 9=brother/sister 10=grandparent	11=uncle/aunt 12=cousin 13=nephew/niece 14=parent in-law 15=brother-in-law/sister-in-law 16=other relative 17=non-relative 18=child in temporary care 19=foster child 20=foster parent	REASON TEMPORARILY AWAY	if 4B=4: WHERE CHILD LIVES MOST

IF 4B=5, CAPI WILL DISPLAY APPROPRIATE 4C QUESTION:

Q4C. IF 4B=5: “Where does [NAME] live most of the time: READ LIST

1= More than half of the time here in this household

2= More than half of the time in another household

3=About equal time here and in another household

IF STATE AGENCY INCLUDES CHILDREN IN TEMPORARY CARE IN FAMILY ECONOMIC UNIT, CAPI WILL SKIP THIS MODULE

IF STATE AGENCY EXCLUDES CHILDREN IN TEMPORARY CARE FROM FAMILY ECONOMIC UNIT, CAPI WILL DISPLAY THIS MODULE

CHILDREN IN TEMPORARY CARE

IF STATE AGENCY EXCLUDES CHILDREN IN TEMPORARY CARE OF FRIENDS OR RELATIVES FROM THE FAMILY ECONOMIC UNIT, AND THERE ARE ONE OR MORE CHILDREN AGED 15 OR YOUNGER IN THE HOUSEHOLD, THEN ASK:

“Sometimes, children stay with another family who takes care of them temporarily. Does this apply to any of the children (other than [NAME OF SAMPLED INFANT/CHILD]) you’ve listed? I’m going to read the name of each child who is 14 years old or younger. If you/your family were providing temporary care to that child in [MONTH OF CERT DATE], please answer ‘Yes.’”

LIST OF CHILDREN WHERE AGE < 15 YEARS AND CHILD IS NOT A FOSTER CHILD AND NOT = SAMPLED INFANT/CHILD PARTICIPANT

“Were you or your family, providing temporary care to:

NAME OF first CHILD	 Yes	Q4 SET TO 18 CHILD WILL BE EXCLUDED FROM EU
NAME OF second CHILD	 Yes	Q4 SET TO 18 CHILD WILL BE EXCLUDED FROM EU
…

SHARED OR SEPARATE FINANCES

CAPI WILL AUTOMATICALLY DISPLAY NAME, GENDER, AGE AND (IF APPLICABLE) REASON TEMPORARILY AWAY OF EACH PERSON. INTERVIEWER WILL READ THE AGE-APPROPRIATE QUESTION AND SELECT RESPONSE IN COLUMN Q6:

“Next, I’m going to ask whether you shared income and expenses with each person who was living with [NAME OF SAMPLED CHILD] in [MONTH OF CERT_DATE].”

IF AGE ≥ 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF CERT_DATE], you were sharing income and expenses as if you were a family – OR do you feel that you each kept your income and expenses and food separately?”

• Yes, share: SELECT “SHARE LIKE FAMILY” FOR NAME

• No, keep separate: SELECT “SEPARATE” FOR NAME

IF AGE < 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF CERT_DATE], you were responsible for taking care of them as if you were all in the same family?”

• Yes, responsible for taking care of: SELECT “SHARE LIKE FAMILY” FOR NAME

• No, not responsible for taking care of: SELECT “SEPARATE” FOR NAME

PREFILLED					INTERVIEWER SELECTS
	Q1	Q2	Q3	Q4B	Q6
	NAME	GENDER	AGE	REASON TEMPORARILY AWAY	Family or Separate?13
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	NA	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	(1-6 code)	 1=share like family  2=separate
R#.	name	(1 or 2)	(age)	(1-6 code)	 1=share like family  2=separate

IF NECESSARY FOR MEMBERS TEMPORARILY AWAY, PROBE:

• NAME IS AGE ≥ 15 YEARS: “When [NAME] is here, do you and [NAME] share income and expenses?”

• NAME IS AGE < 15 YEARS: “When [NAME] is here, do you help take care of [NAME] as if you were all in the same family?”

PREGNANT FAMILY MEMBERS

P1. “Were you, or was anyone in your household, pregnant at your recent certification appointment at the WIC office?

• Yes GO TO P2

• No GO TO CONFIRM SIZE OF FAMILY EU

P2. “Who was pregnant on CERT_DATE?”
<SELECT NAME FROM Q1 LIST DROPDOWN MENU>	IF PREGNANT MEMBER SHARES FINANCES (Q6=1), GO TO P2A. IF PREGNANTMEMBER HAS SEPARATE FINANCES (Q6=2), GO TO P2D

P2A. “Were you/Was [NAME] expecting a single infant, twins or multiples?” (DO NOT READ OPTIONS)

• SINGLETON IF SHARED FINANCES, CAPI WILL ADD 1 TO FAMILY ECONOMIC UNIT. GO TO P2B

• TWINS IF SHARED FINANCES, CAPI WILL ADD 2 TO FAMILY ECONOMIC UNIT. GO TO P2B

• MULTIPLES [ENTER NUMBER FROM 3 OR HIGHER] IF SHARED FINANCES, CAPI WILL ADD [N] TO FAMILY ECONOMIC UNIT. GO TO P2B

P2B. “Since that appointment have you/has [NAME] given birth?” (DO NOT READ OPTIONS)

• YES GO TO P2C

• NO [STILL PREGNANT OR PREGNANCY ENDED] GO TO P2D

P2C. “Have you already listed the infant/infants that you/that [NAME] gave birth to as part of your household above?” [CONFIRM THAT THE SAME NUMBER OF INFANTS FROM PREGNANCY (P3) ARE ALREADY LISTED IN HOUSEHOLD ENUMERATION CHART] (DO NOT READ OPTIONS)

• YES, WITH [N] BABIES LISTED CAPI WILL SUBTRACT [N] FROM FAMILY ECONOMIC UNIT

• NO, BABY DOES NOT LIVE IN UNIT/DIED/ETC GO TO P2D

P2D. Was anyone else pregnant on CERT_DATE? REPEAT P4-P4D AS NEEDED UNTIL P2D=NO.

• YES GO TO P2

• NO GO TO CONFIRMATION OF SIZE OF FAMILY EONOMIC UNIT

CONFIRMATION OF SIZE OF FAMILY ECONOMIC UNIT (EU_SIZE)

CAPI WILL CALCULATE SURVEY_EU_SIZE AND COMPARE TO FAMILY (EU) SIZE FROM WIC RECORDS (WIC_EU_SIZE).

• IF CERT_CAT= PREGNANT, EU_SIZE INCREMENTED BASED ON Q1P1 SERIES OF QUESTIONS

• IF Q4=18 (CHILD IN TEMP CARE) AND STATE EXCLUDES THESE CHILDREN FROM EU, CHILD WILL BE EXCLUDED FROM PARTICIPANT’S EU

• IF Q4=19 (FOSTER CHILD), THE INDIVIDUAL IS EXCLUDED FROM PARTICIPANT’S EU

• IF Q6=2, THE INDIVIDUAL IS EXCLUDED FROM THE PARTICIPANT’S EU.

IF SURVEY_EU_SIZE = WIC_EU_SIZE, CAPI WILL SKIP TO ADJUNCTIVE/AUTOMATIC ELIGIBILITY.

IF SURVEY_EU_SIZE < WIC_EU_SIZE, CAPI WILL PROMPT:

• “My records show that when you applied for WIC for your child, there were [#IN FAMILY] people in his/her family, which is more than we listed today. Have we left someone off the list? Or is there someone on our list who should be counted as part of your child’s main family unit but was not?”

• REVIEW LIST, ADD NAMES/EDIT INFO IF NECESSARY. IF LIST CORRECT, CONTINUE.

IF SURVEY_EU_SIZE > WIC_EU_SIZE, CAPI WILL PROMPT:

• “My records show that when you applied for WIC for your child, there were [#IN FAMILY] people in his/her family, which is less than we listed today. Can you confirm that everyone on our list today is part of your child’s main family unit?”

• REVIEW LIST, SUBTRACT NAMES/EDIT INFO IF NECESSARY. IF LIST CORRECT, CONTINUE.

ADJUNCTIVE OR AUTOMATIC ELIGIBILITY

Q7. IF ADJ OR AUTO ELIGIBILITY in WIC RECORDS=YES: “My records show that you qualified for WIC because your child, or a member of your family, participates in the [ADJ/AUTO PROGRAM NAME]. Can you show me a document to demonstrate participation in that program, such as a certification card, award letter or notice of benefits?”

IF ADJ OR AUTO ELIGIBILITY in WIC RECORDS =NO: “Was your child, or another family member, participating in a benefits program such as Medicaid, SNAP, TANF or [NAME OF STATE PROGRAM(S)] on [CERT_DATE]?”

YES	“Can you show me a document to demonstrate participation in that program, such as the certification card, award letter or notice of benefits?”
WIC LOOKED UP MY NAME IN PROGRAM ENROLLMENT LIST, WEBSITE, OR BY CALLING RELEVANT AGENCY	“Ok, do you have a certification card, award letter or notice of benefits?”
NO	GO TO INCOME SOURCES

PROOF SHOWN	NO PROOF SHOWN (OR WRONG PROOF)	FLAG FOR FOLLOW-UP WITH STATE AGENCY to confirm enrollment in applicable program
NAME OF PROGRAM RECIPIENT	<select name from Q1 list> CHECK THAT NAME MATCHES SOMEONE IN FAMILY EU	IF NAME ON DOCUMENT DOES NOT MATCH PARTICIPANT’S NAME:	If program is SNAP or FDPIR and NAME on document is member of PARTICIPANT’s family (Q6=share like family), then acceptable proof. If program is Medicaid and NAME on document is a pregnant woman or infant and a member of the PARTICIPANT’s family (Q6=shared), then acceptable proof. If program is TANF and NAME on document is a member of PARTICIPANT’s family (Q6=shared), then acceptable proof.
Date of document/card issuance (mm/dd/yyyy)	TYPE IN: mm/dd/yyyy 99 No date PROBE: Do you have anything that shows the dates of your participation?
Date enrollment expires (mm/dd/yyyy)	TYPE IN: mm/dd/yyyy 99 No date PROBE: Do you have anything that shows the expiration date?
Name of issuing agency	TYPE IN: 99 Not evident PROBE: Do you have anything that shows the agency name?
Number on document/card	TYPE IN: 99 No number
Type of document/card shown:
Certification card Award letter EBT transaction receipt or activity statement w/deposit no greater than 30 days prior to CERT_DATE Other:

CAPI WILL GO TO INCOME SOURCES EVEN IF ADJUNCTIVELY/AUTOMATICALLY INCOME ELIGIBLE: [Note for reviewers: NSWP-III research objectives call for estimate of WIC participant’s income, regardless of adjunctive income eligibility status]

INCOME: ALTERNATE INCOME DETERMINATION PROCEDURE (INDIAN TRIBAL ORGANIZATIONS)

IF ITO=YES AND ALTERNATIVE INCOME PROCEDURE =YES, THE “ALTERNATE INCOME DETERMINATION PROCEDURE” APPLIES. OTHERWISE, CAPI SKIPS ALTERNATE PROCEDURE FOR INCOME DETERMINATION

CAPI PERFORMS A LOOKUP AGAINST TABLE OF INCOME ELIGIBILITY GUIDELINES (IEGs) BASED ON SIZE OF FAMILY ECONOMIC UNIT. CAPI DISPLAYS INCOME THRESHOLD [INCOME_MAX].

ID8 “On [CERT_DATE], was your family’s income at or below $[INCOME_MAX]?”

YES	GO TO ID8A
NO	GO TO INCOME SOURCES (Q8a)

INCOME SOURCES

“Now I’m going to ask you about the income received by you and other primary members of your family unit. Your name, your child’s name, your address and other information that identifies you or your family will not be included in study reports. The information we collect will be combined with information from other people in this study from across the U.S. We won’t share personal information about you with your local WIC agency, other benefit programs, your landlord, bank, employer, or people in your community. None of your WIC benefits will change as a result of this survey.”

Q8a. At the time of your most recent certification appointment (on or before [CERT_DATE]), [were you /was NAME] unemployed – that is, had you/NAME been working but stopped?

• Yes GO TO Q8b

• No GO TO INCOME SOURCES

Q8b. About how long had you/NAME been unemployed as of CERT_DATE? READ LIST:

• Less than 30 days before CERT_DATE

• 1 month or longer before CERT_DATE

GO TO Q9

Note for reviewers: The next set of questions asks for income sources and amounts during the 30 days prior to the participant’s certification date. Federal WIC regulations (Section 246.7(d)(2)(i)) permit State agencies to instruct local agencies to determine whether the current rate of income or income over the prior 12 months most accurately reflects the family status (with two exceptions described below). Although policy guidance provides some recommendations, this regulation gives local agencies some flexibility to make independent and non-replicable decisions about which timeframe is more accurate. As a result, FIs will first assess family income based on the current rate of income (defined as the 30 days prior to certification date). If preliminary results suggest that the WIC participant should have been deemed ineligible due to income, the FI will re-assess the family’s income using a reference period of at least 30 days that falls sometime within the year prior to CERT_DATE. The FI will first attempt to obtain income documentation for a total of 30 days during the three months prior to CERT_DATE. Given that families may have sparse documentation for income from prior periods, the FI will accept any proof of income that spans a total of 30 days within the past six months. (For income from self-employment, rental income and royalties, FIs will have already requested proof of income over the past 12 months.)

There are two exceptions to the Federal regulations granting flexibility regarding the income timeframe: (1) for families with an unemployed person agencies must determine income eligibility based on current rate of income; (2) for families with an instream migrant worker whose Verification of Certification card is expired, agencies must consider the family to be income eligible so long as the income is redetermined once every 12 months. IF WIC PARTICIPANT’S MIGRANT STATUS =YES, LACK OF DOCUMENTATION OF INCOME WILL NOT RESULT IN “INCOME INELIGIBLE” DETERMINATION.

Q9A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ LIST IN COLUMN A. CHECK ONLY IF YES.

Q9B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Wages, salary or fees (excluding military pay)	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Datex Once/lump sum Other: ____
INSTRUCTIONS for Wages, salary or fees (excluding military pay): Use one row per income document. If the income period covers less than one month’s pay (less than 28 days total), you will need more than one paystub or documentation of income from wages, salary or fees. Be sure to enter the income period. If the pay period is not stated on a paycheck or pay statement, enter the date the check or was issued and PROBE for the frequency of pay: Does this income cover one week of work, two weeks, half of the month, one month of work, or some other duration? Income documents are listed in order of preference. Preferred documentation types are underlined. Less preferred options are gray and not underlined. Try to obtain a preferred document type. Record the GROSS pay before deductions for taxes, insurance, or any other amounts withheld from the net pay. If Net Pay is the only amount available from any source, record the Net dollar amount and check the box in the Amount column to indicate that the dollar amount reflects net pay.
IF FREQUENCY IS PER TWO WEEKS OR TWICE/MONTH, PROMPT: Do you have another paystub/document showing the amount you received in the weeks just before [just after] the period covered in this one? IF FREQUENCY IS PER WEEK, PROMPT: Do you have other paystubs/documents showing the amount you received in the weeks before [after] this week? PROMPT: Did you have wages, salary or fees from any other job in the month before CERT_DATE?
Wages, salary or fees (additional paystub)	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Wages, salary or fees (additional paystub)	From: mm/dd/yy To: mm/dd/yy	Check one, use addtl rows if nec: Paystub/earnings statement Employer statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $ Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
 CLICK TO ADD ROW FOR ADDITIONAL Wages, salary or fees

^x Year to Date will appear in Income Sources: Frequency as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Tips, bonuses, or commissions (POSSIBLE LUMP SUM)	From: mm/dd/yy To: mm/dd/yy	Paystub/earnings statement Employer statement Business records (for commissions) Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Income from self-employment (farm or non-farm) (NET INCOME)	From: mm/dd/yy To: mm/dd/yy	2017 IRS tax return, 1099 Business records Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Rental income (NET INCOME)	From: mm/dd/yy To: mm/dd/yy	Rental agreement, lease, other business records Cancelled rent check 2017 IRS tax return, 1099 Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Royalties (PROMPT FOR ITOs: per capita payments) (NET INCOME) (POSSIBLE LUMP SUM) (POSSIBLE EXCLUSION)	From: mm/dd/yy To: mm/dd/yy	Paystub/earnings statement Deposit on bank statement 2017 IRS tax return, 1099 Business records Other [textbox] NONE (self-reported)	NET $	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

^x Year to Date will appear in Income Sources: Frequency as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Unemployment compensation	From: mm/dd/yy To: mm/dd/yy	Benefit letter/letter of determination Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
IF PARTICIPANT/FAMILY MEMBER INDICATES NO INCOME FROM UNEMPLOYMENT COMPENSATION BUT WAS UNEMPLOYED (Q8A), ASK: UE1. “Did you apply for unemployment benefits?” Yes GO TO UE2 No CONTINUE TO NEXT INCOME SOURCE UE2. “Was your application denied or approved?” DO NOT READ LIST Denied/turned down CONTINUE TO NEXT INCOME SOURCE Approved GO TO UE3 Have not heard back/never heard back CONTINUE TO NEXT INCOME SOURCE UE3. “Okay, you were approved to get unemployment, but you have not received any income from unemployment compensation. Can you show me a copy of the approval letter?” Yes RECORD DATE OF LETTER AND AMOUNT OF BENEFITS AWARDED No CONTINUE TO NEXT INCOME SOURCE
Workers compensation	From: mm/dd/yy To: mm/dd/yy	Benefit letter/letter of determination Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Social security benefits	From: mm/dd/yy To: mm/dd/yy	Award letter from SSA Statement of benefits Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

^x Year to Date will appear in Income Sources: Frequency as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Federal SSI (Supplemental security income)	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
State SSI or State disability insurance	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Public assistance or TANF	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Energy assistance (amount will be excluded, per WIC regulations)	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Possible income exclusions or lump sums (SEE INCOME PROBE QUESTIONS): Vouchers received under the Workforce Investment and Opportunity Act to cover cost of job training or employment such as transportation, uniforms, or child care. Payments to the Confederated Tribes and Bands of certain Indian Tribes listed in WIC regulations Value of SNAP or WIC food instruments issued to family member

^x Year to Date will appear in Income Sources: Frequency as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Alimony or child support (1st source)	From: mm/dd/yy To: mm/dd/yy	Check or check stub Support agreement Divorce/separation decree Court order Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Alimony or child support (2nd source)	From: mm/dd/yy To: mm/dd/yy	Check or check stub Support agreement Divorce/separation decree Court order Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Any government or private pension, annuity or survivor’s benefits	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Disbursement from an estate or trust	From: mm/dd/yy To: mm/dd/yy	Earnings statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____

^x Year to Date will appear in Income Sources: Frequency as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Interest or dividends	From: mm/dd/yy To: mm/dd/yy	Earnings or dividend statement Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Withdrawals from a savings or investment account	From: mm/dd/yy To: mm/dd/yy	Withdrawal receipt/slip Earnings statement Withdrawal on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Possible income exclusions or lump sums (SEE INCOME PROBE QUESTIONS): Payments to American Indian Tribes/Tribal members (SEE EXCLUSIONS LIST) The value of payments (subsidies) for the provision of child care services for low-income families The value of any rental assistance (vouchers), lower mortgage rates, loan guarantees to support home ownership by low-income families (see the Cranston-Gonzales National Affordable Housing Act Housing and Community Development Act of 1987

^x Year to Date will appear in Income Sources: Frequency as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: COLUMN A. CHECK ONLY IF YES.

B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

9A Income Type	9B Income Period	9C Proof of Income Document	9D Amount	9E Frequency
Veteran’s payments	From: mm/dd/yy To: mm/dd/yy	Notice of benefits Check or check stub Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Possible income exclusions or lump sums (SEE INCOME PROBE QUESTIONS): Any veteran’s compensation to a Vietnam veteran or veteran who served in Korea in 1968 or 1969 who was exposed to the herbicide known as “Agent Orange”
Military pay (EXCLUSIONS APPLY.CAPI TAKES INTERVIEWER TO MILITARY PAY MODULE)	From: mm/dd/yy To: mm/dd/yy	Leave and Earnings Statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Regular contributions from someone not in household	From: mm/dd/yy To: mm/dd/yy	Letter from payer, dated & signed Deposit on bank statement Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Other income sources (SEE INCOME PROBE QUESTIONS)	From: mm/dd/yy To: mm/dd/yy	Earnings statement Benefit/award letter Letter from payer, dated & signed Deposit on bank statement 2017 IRS tax return, W2, 1099 Other [textbox] NONE (self-reported)	Gross $  Net pay (check if gross pay unavailable)	Per week Per 2 weeks Twice/month Per month	Per quarter Per year Year To Date Once/lump sum Other: ____
Possible income exclusions or lump sums (SEE INCOME PROBE QUESTIONS): Payments received under the Carl D. Perkins Vocational Education Act or Carl D. Perkins Vocational Applied Technology Education Act Amendments of 1990 Student financial assistance under Title IV of Higher Education Act used for tuition fees, books, equipment materials or supplies required of students for the course of study, including Pell Grant, Supplemental Educational Opportunity Grant (SEOG), State Student Incentive Grant, National Direct Student Loan, PLUS, College Work Study Loans

^x Year to Date will appear in Income Sources: Frequency as an option only if the Alternate Income Reference Period applies.

ZERO INCOME REPORTED

IF PARTICIPANT DID NOT QUALIFY AS ADJUNCTIVELY/AUTOMATICALLY INCOME ELIGIBILITY FOR WIC AND PARTICIPANT’S TOTAL INCOME = $0 AND NO ADULT ≥ 15 YEARS WAS REPORTED TO HAVE SEPARATE FINANCES (Q6=2), CAPI WILL DISPLAY INTRO AND Z1b-Z2; IF ANY ADULT AGE ≥ 15 YEARS WAS REPORTED TO HAVE SEPARATE FINANCES (Q6=2), CAPI WILL DISPLAY ALL ITEMS:

INTRO: “If I understand your answers correctly, it looks like you had zero income on [CERT_DATE].

Z1. You said that [NAME] and [NAME] were not part of your family group. Was/Were [LIST NAMES WHERE Q6=SEPARATE FINANCES], or was anyone that you haven’t named helping you to pay for living expenses such as rent/mortgage, heat, or food on [CERT_DATE]?

• Yes GO TO Z1a

• No GO TO Z1b

Z1a. “In that case, I need to ask you about [NAME]’s income. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [NAME] have any income from [REPEAT Q9a for NAME FOR EACH TYPE OF INCOME SOURCE]. CAPI WILL PROMPT INTERVIEWER TO CHANGE THE RESPONSE TO Q6 FOR [NAME(S)] TO Q6=1 SO THAT THIS INDIVIDUAL IS COUNTED AS PART OF PARTICIPANT’S FAMILY

Z2. “I’d like to better understand how you were paying for living expenses in [MONTH, YEAR OF CERT_DATE]. Can you tell me if any of the following were true: CHECK ALL THAT APPLY

I had applied for public assistance but did not received payment until after [MONTH, YEAR OF CERT_DATE] (IF NECESSARY: such as Temporary Assistance to Needy Families (sometimes called welfare) or Food Stamps).	REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, PUBLIC ASSISTANCE
I had applied for workers compensation but did not received payment until after [MONTH, YEAR OF CERT_DATE]	REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, WORKER’S COMPENSATION
I received some emergency cash from a church, charity, or social services agency or food from a food bank	ENTER AMOUNT IN Q9, OTHER CASH
I skipped one or more rent, mortgage or utility payments
I did some work such as child care, housework, or another service in exchange for reduced rent or food	IN-KIND BENEFITS NOT INCOME
OTHER: “Can you describe how you paid for living expenses then?” TYPE IN RESPONSE: ____	IF ANY INCOME SOURCES RETURN TO Q9
NONE OF THE ABOVE

AFTER Z2 GO TO END OF SURVEY

ALTERNATE INCOME REFERENCE PERIOD

CAPI WILL MAKE A PRELIMINARY DETERMINATION OF INCOME ELIGIBILITY BASED ON MOST RECENT 30 DAYS’ INCOME PRIOR TO CERTIFICATION DATE REVIEWED.

IF PRELIM_INCOME_ELIG=YES, THEN CAPI WILL SKIP TO END OF CERTIFICATION SURVEY.

IF PRELIM_INCOME_ELIG= NO, THEN CAPI WILL DISPLAY THE FOLLOWING ON-SCREEN.

“I need to be sure we’ve come up with the best estimate of your typical income. We just went over your family’s income during the month before your certification appointment at WIC.”

Q10. During that month, did you, or anyone else I’m going to name, have income that was higher than usual?

	YES	NO
Let’s start with you [WIC PARTICIPANT]: was your income during the month before [CERT_DATE] higher than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period higher than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period higher than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period higher than usual?		

FOR EACH FAMILY MEMBER WHERE Q10=YES, COMPUTER WILL LOOP BACK THROUGH THE INCOME SOURCES USING ALTERNATE REFERENCE PERIOD FOR INCOME PROOF:

“It looks like I may have overestimated your family’s typical income.”

10A. “I’d like you now to think back about three months before [CERT_DATE]: So, I’m talking about [MONTH EQUAL TO CERT_DATE‒90 DAYS] to [MONTH EQUAL TO CERT_DATE ‒60 DAYS]. During that time, did [YOU/FAMILY MEMBER WHERE Q10=YES] have any income from [REVIEW EACH SOURCE IN COLUMN A]. IF INCOME REPORTED ASK 10B, IF NO INCOME FROM THAT SOURCE GO TO NEXT INCOME SOURCE.

IF NO DOCUMENTATION FOR 3^RD MONTH BEFORE CERT_DATE, REQUEST DOCUMENTATION FOR 2^ND MONTH BEFORE CERT_DATE;

IF NO DOCUMENTATION FOR 2^ND MONTH BEFORE CERT_DATE, THEN REQUEST DOCUMENTATION FOR 4^TH MONTH BEFORE CERT_DATE.

IF NO DOCUMENTATION 4^TH MONTH BEFORE CERT_DATE, REQUEST DOCUMENTATION FOR 5^TH MONTH BEFORE CERT_DATE.

IF NO DOCUMENTATION FOR 5^TH MONTH BEFORE CERT_DATE, REQUEST DOCUMENTATION FOR 6^TH MONTH BEFORE CERT_DATE. IF NONE, END LOOP [DO NOT REQUEST DOCUMENTATION OLDER THAN 6 MONTHS PRIOR TO CERT_DATE].

10B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]

END OF CERTIFICATION SURVEY

IF PARTICIPANT IS ALSO IN THE SAMPLE FOR THE PROGRAM EXPERIENCES SURVEY:

“Ok, that’s the end of the first part. Here is the first $25 gift card. Next, I’d like to ask about your experiences with the WIC program and your satisfaction with various WIC benefits and services. This next part will take about [ESTIMATED BURDEN OF PROGRAM EXPERIENCE SURVEY] minutes. Afterwards, I’ll give you another $25 gift card. [GO TO PROGRAM EXPERIENCES SURVEY]

IF PARTICIPANT IS NOT IN THE SAMPLE FOR THE PROGRAM EXPERIENCES SURVEY:

“Ok, this completes our survey. It was great talking with you, and thank you so much for helping us out. Here is a $25 gift card in appreciation for your time.

SEE BELOW FOR MILITARY PAY MODULE AND INCOME PROBE QUESTIONS MODULE

MILITARY PAY MODULE¹⁴

Using the service member’s military Leave and Earnings Statement, enter the information below. Some pay codes will prompt you to ask clarifying questions that will automatically display. Answering the questions will determine the Income Treatment Code in the rightmost column.

Last Name		First Name		MI	Pay Date	Branch	Period Covered
ENTITLEMENTS
A	Type		Amount		Income treatment codes
B	ENTER PAY CODE		$ .
C	ENTER PAY CODE		$ .		EXCLUDE: BAH
D	ENTER PAY CODE		$ .		EXCLUDE: OCONUS COLA
E	ENTER PAY CODE		$ .
F	ENTER PAY CODE		$ .		ANNUALIZE
G	ENTER PAY CODE		$ .
H	ENTER PAY CODE		$ .
I	ENTER PAY CODE		$ .		EXCLUDE: COMBAT PAY
J	ENTER PAY CODE		$ .
K	ENTER PAY CODE		$ .
L	ENTER PAY CODE		$ .
M	ENTER PAY CODE		$ .
N	ENTER PAY CODE		$ .
O	ENTER PAY CODE		$ .
	REMARKS: ENTER any PAY CODES listed in REMARKS		$ .
	TOTAL		$ .		Countable income after exclusions and annualizations =

POSSIBLE LUMP SUM PAYMENT:

“Does [NAME] receive this pay, [PAYCODE], once a year, monthly, or with some other frequency?”

• Once per year

• Quarterly

• Monthly

• OTHER: SPECIFY FREQUENCY OR PAY INTERVAL

IF FREQUENCY IS ONCE/YEAR OR QUARTERLY, THEN THE AMOUNT WILL BE ANNUALIZED. OTHERWISE ALL AMOUNTS ARE ASSUMED MONTHLY

POSSIBLE COMBAT PAY:

SELECT YES OR NO FOR EACH QUESTION

	YES	NO
Does [NAME] receive this pay in addition to the base pay?		
Is this pay the result of deployment to a designated combat zone?		
Does [NAME] only receive this pay while deployed to the combat zone?		

IF YES TO ALL THREE QUESTIONS, THE PAY IS COMBAT PAY (AND WILL BE EXCLUDED FROM TOTAL INCOME)

IF NO, TO ANY QUESTION, THE PAY IS NOT COMBAT PAY AND WILL BE INCLUDED AS INCOME.

Table 3. Military Pay Codes

Code	Type of Pay	Counts as Income unless noted otherwise
AB	Accession bonus	Ask Lump Sum
ACIP	Aviation Career Incentive Pay
ACP	Aviation Continuation Pay
AIP	Assignment Incentive Pay	Ask Combat Pay
ASP	Additional Special Pay
BAH	Basic Allowance for Housing	if State excludes, Exclude
BAS	Basic Allowance for Subsistence
BAQ	Basic Allowance for Quarters	if State excludes, Exclude
Base Pay	Base Pay
BCP	Board Certified Pay Special Pay
CCA	Civilian Clothing Allowance	Ask Lump Sum
BRA	Basic Replacement Allowance	Ask Lump Sum
Continuation Pay	Continuation Pay
CCCA	Continuing Civilian Clothing Allowance	Ask Lump Sum
CCRA	Cash Clothing Replacement Allowance	Ask Lump Sum
CEFIP	Career Enlisted Flyer Incentive Pay
CIP	Combat-related Injury & Rehabilitation	Ask Combat Pay
CMA	Clothing Maintenance Allowance or Clothing Allowance
CONUS COLA	Continental U.S. Cost of Living Allowance	Exclude, in-kind benefit
Combat Duty or Combat Zone Pay	Combat Duty or Combat Zone Pay	EXCLUDE
CRA	Clothing Replacement Allowance	Ask Lump Sum
CSP	Career Sea Pay
CSP-P	Career Sea Pay – Premium
CSRB	Critical Skills Retention Bonus	Ask Lump Sum
CVI	Conditional Voluntary Indefinite Status
DLA	Dislocation Allowance	Exclude, in-kind benefit
Dive Pay	Dive Pay	Ask Combat Pay
DSCT Meal	Discount Meal	Exclude, in-kind benefit
FDP	Foreign Duty Pay	Ask Combat Pay
FLPP	Foreign Language Proficiency Pay	Ask Combat Pay
Flight or Fly Pay	Flight or Fly Pay	Ask Combat Pay
FSA	Family Separation Allowance	Ask Combat Pay
FSH	Family Separation Housing	Exclude, in-kind benefit
FSSA	Family Subsistence Supplemental Allowance	EXCLUDE
HALO	High Altitude/Low Altitude	Ask Combat Pay
HDIP	Hazardous Duty Incentive Pay	Ask Combat Pay
HDP – Involuntary Extension	Hardship Duty Pay – Involuntary Extension	Ask Combat Pay
HDP – L	Hardship Duty Pay - Location	Ask Combat Pay
HDP – M	Hardship Duty Pay – Mission	Ask Combat Pay
HFP/IDP	Hostile Fire/Imminent Danger Pay	Ask Combat Pay
HFP-L	Hostile Fire Pay - Location	Ask Combat Pay
HZD	Hazardous Duty Pay	Ask Combat Pay
ICCA	Initial Civilian Clothing Allowance	Ask Lump Sum
IDP	Imminent Danger Pay Note: Can also mean Independent Duty Corpsman	Ask Combat Pay
ISP	Incentive Special Pay
Jump Pay	Jump Pay	Ask Combat Pay
LQA	Living Quarters Allowance	Exclude, in-kind benefit
Maternity Clothing Allowance	Maternity Clothing Allowance	Ask Lump Sum
MIHA – Miscellaneous	Moving Housing Allowance - Miscellaneous	Exclude, in-kind benefit
MIHA – Rent	Moving Housing Allowance – Rent	Exclude, in-kind benefit
MIHA – Security	Moving Housing Allowance - Security	Exclude, in-kind benefit
MRB	Multiyear Retention Bonus
MSP	Multiyear Special Pay
NIB	Nuclear Career Annual Incentive Bonus
NPAB	Nuclear Power Accession Bonus	Ask Lump Sum
Nuclear – Continuation Pay	Nuclear – Continuation Pay
OEP	Overseas Extension Pay
OHA	Overseas Housing Allowance	Exclude, in-kind benefit
OCONUS COLA	Overseas Continental United States Cost of Living Allowance	if State excludes, Exclude
OTEIP	Army Overseas Tour Extension Incentive Pay
OVERSEAS COLA	Overseas Cost of Living Allowance	Exclude, in-kind benefit
Overseas Extension Pay	Overseas Extension Pay
PCCA	Partial Civilian Clothing Allowance	Ask Lump Sum
RBMA	Reserve Basic Maintenance Allowance
SBP	Military Survivor Benefits Plan
SAVE PAY	Save pay Note: This can represent many types of pay. Ask questions to determine what the pay is for to see if it counts. Often refers to difference in pay due to accepting a new appointment between new and old pay rates. Likely to be a lump sum.	Caution: ask if lump sum
SDAP	Special Duty Assignment Pay	Ask Combat Pay
SDIP	Submarine Duty Incentive Pay	Ask Combat Pay
Sea Pay	Sea Pay	Ask Combat Pay
SEA	Subsistence Expense Allowance
SEB	Selective Enlistment Bonus	Ask Lump Sum
SepRats	Separation Rations
SMA	Standard or Separate Maintenance Allowance
Special Duty Pay	Special Duty Pay	Ask Combat Pay
Specialty Pay	Specialty Pay	Ask Combat Pay
SPO	Split Payment Option Note: This option allows the person to take an amount from the base pay and put it into the ship ATM for personal use while on board. Base WIC income eligibility on the gross amount before the split allocation. Don’t count the amount sent to the ship account twice.	Caution
SR	Separation Rations
SRA	Standard Replacement Allowance	Ask Lump Sum
SRB	Selective Reenlistment Bonus	Ask Lump Sum
Standard Initial Clothing Allowance	Standard Initial Clothing Allowance	Ask Lump Sum
Submarine Pay	Submarine Pay
SUPP CMA	Enlisted Supplemental Clothing Allowance	Ask Lump Sum
TDYCCA	Temporary Duty Civilian Clothing Allowance	Ask Lump Sum
TLE CONUS	Temporary Lodging Expense in US	Exclude, in-kind benefit
TLA	Temporary Living Allowance	Exclude, in-kind benefit
TLA OCONUS	Temporary Lodging Allowance Outside US	Exclude, in-kind benefit
TQSA	Temporary Quarters Subsistence Allowance
VI	Voluntary Indefinite Status
VBSS Duty	Maritime Visit, Board, Search & Seizure Duty
VSP	Variable Special Pay

INCOME PROBE QUESTIONS (POSSIBLE EXCLUSIONS OR LUMP SUMS)

AT ANY TIME WHILE ASKING PARTICIPANT ABOUT INCOME SOURCES (Q9), THE INTERVIEWER MAY BRING UP A LIST OF THE FOLLOWING POTENTIAL LUMP SUM OR INCOME EXCLUSION QUESTIONS:

If participant is a member of an American Indian Tribe and:

ASK/DO

Reports income from the government or Tribe

“Did you receive this income as part of a settlement or agreement between the U.S. government and an American Indian tribe or Nation?” EXCLUDE ANY SUCH INCOME15 “Is this income a ‘per cap’ or per capita payment from a business operated by members of an American Indian tribe or Nation to which you belong?” ENTER NET AMOUNT UNDER ROYALTIES. ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED

If participant or income document refers to:	ASK/DO
Section 8, housing voucher, rental assistance	“Is this a voucher to help you afford housing or rent?” ANY AMOUNT SHOWN ON A HOUSING CHOICE VOUCHER IS NOT COUNTED AS INCOME. DO NOT ENTER AS AN INCOME SOURCE.16
Child care or day care voucher, child care or day care assistance	EXCLUDE ANY REPORTED PUBLIC ASSISTANCE OR SUBSIDY FOR DAY CARE OR CHILD CARE COSTS17
Food Stamps, Free or Reduced Price Lunch or Breakfast for child in public school, WIC food instruments provided to other WIC participants in family	EXCLUDE ANY REPORTED PUBLIC ASSISTANCE WITH MEALS OR FOOD, INCLUDING ANY REPORT OF FREE MEALS A CHILD RECEIVES AT SCHOOL, FOOD INSTRUMENTS RECEIVED BY ANY FAMILY MEMBER FROM SNAP, FDPIR, OR WIC.18
Job assistance, employment training, Employment Services Program, Job Corps, Youth Build, job training, American Job Center, Workforce Investment, Employment Training, Career Pathway	“Was this income to reimburse you for transportation, child care costs or other expenses so that you could take part in job training, get a GED or take classes that will prepare you for employment?” EXCLUDE REIMBURSEMENTS FOR THESE EXPENSES 19
Volunteer, AmeriCorps, VISTA	“Was this income you received as a volunteer for AmeriCorps, AmeriCorps VISTA or AmeriCorps National Civilian Community Corps (NCCC)?”20
Bonus/commissions	ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED
Royalties	ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED
Any mention of emergency assistance due to a hurricane, tornado, storm, earthquake, volcano, landslide, mudslide, snowstorm, flood, forest fire	“Did you receive [this] assistance because of a major disaster such as a hurricane, tornado, storm or similar natural event that was declared a federal disaster?” FEMA maintains a list of federal disasters each year: https://www.fema.gov/disasters/grid/year/2015. EXCLUDE ANY ASSISTANCE DUE TO FEDERAL DISASTER FROM INCOME SOURCES21
Any mention of loss of property due to flood/hurricane	“Did this income come from FEMA or the National Flood Insurance Program after filing a claim for flood damage to your home? EXCLUDE ANY INCOME DUE TO APPROVED FLOOD DAMAGE CLAIM22
Veteran’s or VA payment, VA disability	“Did you/NAME receive payment because you were exposed to Agent Orange while serving in Vietnam or Korea?” EXCLUDE ANY AMOUNT DUE TO EXPOSURE TO AGENT ORANGE. INCLUDE ALL OTHER VETERAN’S PAYMENTS23
Loan, Student loan	“Is this income part of a loan that you must repay?” EXCLUDE ANY LOAN AMOUNT FROM INCOME SOURCES unless the loan is an amount to which the participant has constant access (e.g., regular contributions from someone not in the household)24

1 Although WIC policy guidance indicates that agencies should determine whether or not separate family economic units have “adequate income” to “sustain the economic unit” and that the “actual living and support costs for the economic unit in that environment must be considered,” the guidance does not indicate how agencies should determine these “actual living and support costs” or what threshold relative to these costs would suffice as “adequate.” Because these judgments are inherently subjective, the NSWP-III cannot independently confirm or disconfirm an independent judgment made by staff at a local WIC agency. If a Participant indicates that a resident of the household maintains separate finances, the NSWP-III will treat those persons as economic unit(s) separate from the participant’s economic unit.

2 See Table 3 for specific military pay codes and proposed exclusions. WIC regulations allow States to choose whether or not to exclude the military Basic Allowance for Housing (BAH) and Cost-of-living allowance for service members stationed outside the contiguous United States (OCONUS COLA) (See 246.7(2)(d)(iv)(A). WIC regulations require States to exclude from income payments to service members from the Family Supplemental Subsistence Act (FSSA) and combat pay. In the context of military pay, WIC Policy Memorandum 2013-3 indicated that “in-kind benefits, such as military on-base housing or other subsidized housing, medical and dental benefits are services that do not meet the definition of ‘income’ and may not be considered in income eligibility determinations.”

3 WIC regulations include income exclusions for multiple types of payments to members of American Indian Tribes from various treaties, agreements or settlements with the U.S. government (see 246.7(2)(d)(iv)(D)(4, 6, 7, 9, 10, 21, 24-32)).

4 WIC regulations include income exclusions for multiple forms of housing assistance to low income individuals (see 246.7(2)(d)(iv)(D)(1, 22-23)

5 WIC regulations include income exclusions for payments, or the value of, child care under the Social Security Act or the Child Care and Development Block Grant programs (see 246.7(2)(d)(iv)(D)(17-19)

6 WIC regulations include income exclusions for the value of food assistance from the National School Lunch Program, the Child Nutrition Act or the Food and Nutrition Act (see 246.7(2)(d)(iv)(D)(8).

7 WIC regulations include income exclusions for payments under the Job Training Partnership Act, replaced by the Workforce Investment Act (WIA) and Workforce Investment and Opportunity Act (WIOA). See 246.7(2)(d)(iv)(D)(5).

8 WIC regulations exclude payments to domestic volunteers (VISTA is now part of AmeriCorps). See 246.7(2)(d)(iv)(D)(2)

9 WIC regulations exclude income from assistance received under the Disaster Relief and Emergency Assistance Amendments of 1989, now the Robert T. Stafford Disaster Relief and Emergency Assistance Act. See 246.7(2)(d)(iv)(D)(13)

10 WIC regulations exclude income from assistance to property owners under the National Flood Insurance Program (246.7(2)(d)(iv)(D)(34).

11 WIC regulations exclude income to certain veterans from the Agent Orange Compensation Exclusion Act ((246.7(2)(d)(iv)(D)(15))

12 WIC regulations exclude loans (246.7(2)(d)(iv)(C)).

13 Although WIC policy guidance indicates that agencies should determine whether or not separate family economic units have “adequate income” to “sustain the economic unit” and that the “actual living and support costs for the economic unit in that environment must be considered,” the guidance does not indicate how agencies should determine these “actual living and support costs” or what threshold relative to these costs would suffice as “adequate.” Because these judgments are inherently subjective, the NSWP-III cannot independently confirm or disconfirm an independent judgment made by staff at a local WIC agency. If a Participant indicates that a resident of the household maintains separate finances, the NSWP-III will treat those persons as economic unit(s) separate from the participant’s economic unit.

14 See Table 3 for specific military pay codes and proposed exclusions. WIC regulations allow States to choose whether or not to exclude the military Basic Allowance for Housing (BAH) and Cost-of-living allowance for service members stationed outside the contiguous United States (OCONUS COLA) (See 246.7(2)(d)(iv)(A). WIC regulations require States to exclude from income payments to service members from the Family Supplemental Subsistence Act (FSSA) and combat pay. In the context of military pay, WIC Policy Memorandum 2013-3 indicated that “in-kind benefits, such as military on-base housing or other subsidized housing, medical and dental benefits are services that do not meet the definition of ‘income’ and may not be considered in income eligibility determinations.”

15 WIC regulations include income exclusions for multiple types of payments to members of American Indian Tribes from various treaties, agreements or settlements with the U.S. government (see 246.7(2)(d)(iv)(D)(4, 6, 7, 9, 10, 21, 24-32)).

16 WIC regulations include income exclusions for multiple forms of housing assistance to low income individuals (see 246.7(2)(d)(iv)(D)(1, 22-23)

17 WIC regulations include income exclusions for payments, or the value of, child care under the Social Security Act or the Child Care and Development Block Grant programs (see 246.7(2)(d)(iv)(D)(17-19)

18 WIC regulations include income exclusions for the value of food assistance from the National School Lunch Program, the Child Nutrition Act or the Food and Nutrition Act (see 246.7(2)(d)(iv)(D)(8).

19 WIC regulations include income exclusions for payments under the Job Training Partnership Act, replaced by the Workforce Investment Act (WIA) and Workforce Investment and Opportunity Act (WIOA). See 246.7(2)(d)(iv)(D)(5).

20 WIC regulations exclude payments to domestic volunteers (VISTA is now part of AmeriCorps). See 246.7(2)(d)(iv)(D)(2)

21 WIC regulations exclude income from assistance received under the Disaster Relief and Emergency Assistance Amendments of 1989, now the Robert T. Stafford Disaster Relief and Emergency Assistance Act. See 246.7(2)(d)(iv)(D)(13)

22 WIC regulations exclude income from assistance to property owners under the National Flood Insurance Program (246.7(2)(d)(iv)(D)(34).

23 WIC regulations exclude income to certain veterans from the Agent Orange Compensation Exclusion Act ((246.7(2)(d)(iv)(D)(15))

24 WIC regulations exclude loans (246.7(2)(d)(iv)(C)).