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 Denied Applicant Survey
With Instructions to Interviewers and Reviewers

Table of Contents

Denied Applicant Survey: Version A (Women) 3

Denied Applicant Survey: Version B (Infant/Child) 45

Denied Applicant Survey: Version A (Women)

The NSWP-III Denied Applicant Survey has two similar versions. Version A is used when the sampled applicant was a woman who was applying for WIC benefits for herself. Version B (included separately) is used when the applicant was applying on behalf of an infant or child. The survey respondent for Version B is the adult applicant who sought WIC certification for the infant or child.

Instructions for Reviewers

The Denied Applicant 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 FI 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 applicant sampled for the Denied Applicant Survey; these data elements appear in Table 2 on the next page.

The NSWP-III version of the Denied Applicant Survey is similar in many aspects to the Certification Survey: it includes items needed to make an independent assessment of an applicant’s eligibility under four criteria: proof of identity; proof of residency; categorical eligibility; and income eligibility. However, the Denied Applicant Survey differs substantially from the version used in NSWP-II. The version fielded in NSWP-II was a brief telephone survey that relied heavily on self-report, and no documentation. For example, respondents were asked whether they knew the reason WIC had denied their application and, if so, whether they agreed with WIC’s determination of their ineligibility.

The survey is organized into the following modules:

Table 1: Denied Applicant 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 relevant 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 Applicant in the Sample
Variable	Description
APPLICANT	Name of denied WIC applicant (Last, First, Middle)
CAREGIVER	Name of adult (parent or caregiver) if APPLICANT is infant or child
ADDRESS	Applicant’s address (number, street, apartment number, city, state, zip code)
STATE	Applicant listed in this State’s denied applicant data or in a local agency’s denied applicant data within this State
STATE_ID	State WIC Agency identifier
LOCAL_ID	Local WIC Agency identifier
CLINIC_ID	Local clinic identifier
ITO	Yes/No, denied applicant is from an ITO or an LWA run by an Indian organization or Indian Health Service
APP_CAT	Applicant’s category (as assigned by WIC, if eligible as member of one of the five participant categories: P=pregnant; B=breastfeeding; N=not breastfeeding postpartum; INF=infant; C=child
APP_DATE	Date of most recent certification appointment
ADJUNCT_CK	Yes/No, local agency checked Medicaid, TANF, SNAP program enrollment to see if applicant was adjunctively income eligible
AUTO_CK	Yes/No, local agency checked State-specific program enrollment to see if applicant was automatically income eligible by WIC
MIGRANT	Yes/No, applicant 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	If applicant was pregnant on APP_DATE, number of expected live births if SINGLETON, PREG_NUM=1; if TWINS, PREG_NUM=2; etc.
ID_PROOF	Yes/No, applicant showed valid proof of ID
R_PROOF	Yes/No, applicant showed valid proof of residency
INC_PROOF	Yes/No, applicant showed valid proof of income
INCOME	Total income of the applicant’s economic unit, as determined by WIC on APP_DATE
D_REASON	Reason applicant ineligible for WIC

Denied Applicant Survey (Version A: Women)

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

Last­_Name				First_Name		Applicant Category			Application Date (APP_DATE)	Prior WIC Participant?	Applicant was Migrant?
Doe				Jane		P/B/N/INF/C/ or NONE: NOT CATEGORICALLY ELIGIBLE			mm/dd/yy	Yes/No	Yes/No
State:	MN		City:	Anytown		ZIP:	12345	Street:	100 Main Street
Reciprocity?			Yes/No	Applied for WIC in which State:		ST	Applied in which LWA:		Local Agency in which applicant applied
Family (EU) Size			#	Adjunct/Auto Elig?		Y/N	Adjunctive program name:
ITO?			Yes/No	Alternate income procedure?			Yes/No
IF APPLICANT 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. As you know, we are conducting this survey among people who were turned down for WIC benefits so that we can see if the agency is following correct procedures. We will keep your responses private to the extent allowed by law. Because the interview is private, it cannot change the decision made by WIC. However, if it appears that the local WIC agency may have made a mistake, or if your circumstances have changed since you last applied, you may want to apply for WIC benefits again.

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

Just to be sure we are both on the same page, I am going to be asking questions about the day you applied for WIC on [APP_DATE].

1. “The first question about is identification. Thinking back to [APP_DATE] when you applied for WIC, did the WIC clinic ask you to show something with your name and photograph, or some other type of identification?”

• YES GO TO 1A

• NO GO TO 1C

• DON’T RECALL GO TO 1C

1A.“What form of identification did you show when you applied for WIC on [APP_DATE]?” [IF APPLICANT HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF ID FROM LIST.]

• MARK ID SHOWN AT WIC GO TO 1B

• DIDN’T SHOW ANY GO TO 1C

• DON’T RECALL GO TO 1C

1B. “Can you show me that same form of identification, or some other type of ID?” GO TO NEXT MODULE

1C. “ Can you show me some ID now?” ENTER ID TYPE SHOWN NOW. GO TO 1D

Identification proofs				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 ID shown AT WIC: DURING SURVEY:					
FI Notes			FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

1D. “Was there any reason you were unable to show ID when you applied for WIC on APP_DATE?” DO NOT READ LIST.

 FORGOT TO BRING IT GO TO 1E

 DIDN’T HAVE ANY (PROBE: “Why didn’t you have any ID then?”) GO TO 1E

 DIDN’T KNOW WHAT ID TO BRING GO TO 1E

 THOUGHT I NEEDED DRIVER’S LICENSE, DIDN’T HAVE ONE GO TO 1E

 ID WAS STOLEN GO TO 1E

 HOMELESS GO TO 1E

 LOST MY WALLET/PURSE/ID GO TO 1E

 LOST ID IN A FIRE, FLOOD, OTHER DISASTER GO TO 1E

 WAS EVICTED AND LOST MY ID, OTHER PROPERTY GO TO 1E

 LEFT PARENTS’/PARTNER’S HOME /NO ACCESS TO ID GO TO 1E

 OTHER (SPECIFY: ) GO TO 1E

 NONE OF THE ABOVE GO TO 1E

 DON’T RECALL GO TO 1E

1E. “Did you go back to the WIC clinic sometime after [APP_DATE] with identification?

• YES

• NO

1F. “Do you, or does anyone in your household, work on farms and move from place to place as the season changes?”

• YES (MIGRANT FARMWORKER) GO TO NEXT MODULE

• NO GO TO NEXT MODULE

RESIDENCY: GEOGRAPHIC STATE

IF APPLICANT 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 RESIDENCY, MARK OFF THE TYPE OF RESIDENCY PROOF IN TABLE BELOW AND SKIP TO INCOME ELIGIBILITY MODULE. OTHERWISE GO TO QUESTION 2.

2. “Thinking back to [APP_DATE], when you applied for WIC, did the agency ask you to show something with your name and home address to prove where you live?”

• YES GO TO 2A

• NO GO TO 2C

• DON’T RECALL GO TO 2C

2A. “What did you show that had your home address?” [IF R. HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF RESIDENCY PROOF FROM LIST. MAIL MUST HAVE RESIDENTIAL ADDRESS. P.O. BOX DOES NOT = PROOF OF RESIDENCY. RURAL ROUTE BOX NUMBER IS ACCEPTABLE RESIDENTIAL ADDRESS.

• MARK TYPE OF PROOF SHOWN AT WIC GO TO 2B

• DIDN’T SHOW ANY GO TO 2C

• DON’T RECALL GO TO 2C

2B. “Can you show me that same document or something else with your name and home address?” GO TO NEXT MODULE

2C. “Can you show me something with your home address now?” ENTER TYPE OF PROOF SHOWN NOW. GO TO 2D

Residency proofs	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:		

2D. “Was there any reason you were unable to show proof of where you live when you applied for WIC on [APP_DATE]?” DO NOT READ LIST.

 FORGOT TO BRING IT GO TO 2E

 DIDN’T HAVE ANY (PROBE: “Why didn’t you have any ID then?”) GO TO 2E

 DIDN’T KNOW WHAT TO BRING GO TO 2E

 THOUGHT I NEEDED DRIVER’S LICENSE, DIDN’T HAVE ONE GO TO 2E

 WAS STOLEN GO TO 2E

 HOMELESS GO TO 2E

 LOST MY WALLET/PURSE/ID GO TO 2E

 LOST IN A FIRE, FLOOD, OTHER DISASTER GO TO 2E

 WAS EVICTED AND LOST MY BELONGINGS GO TO 2E

 LEFT PARENTS’/PARTNER’S HOME /NO ACCESS TO PROOF GO TO 2E

 OTHER (SPECIFY: ) GO TO 2E

 NONE OF THE ABOVE GO TO 2E

 DON’T RECALL GO TO 2E

2E. “Did you go back to the WIC clinic sometime after [APP_DATE] with something proving where you lived?

• YES

• NO

2F. “Do you, or does anyone in your household, work on farms and move from place to place as the season changes?”

• YES (MIGRANT FARMWORKER) GO TO NEXT MODULE

• NO GO TO NEXT MODULE

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

ALTERNATE PROCEDURE APPLIES ONLY IF APPLICANT FROM ITO OR LIVES IN REMOTE INDIAN VILLAGE OR PUEBLO. 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 (i). “My records say that you were living in [VILLAGE].

(i) Is there another name for the place you lived at the time of your application appointment?

• YES (RECORD NAME) GO TO ALT 2D

• NO GO TO ALT 2C(ii)

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

3. “Now we’re going to check whether you fit any of the eligible types of WIC participant categories at the time you applied. When you applied for WIC on [APP_DATE], which of the following best describes you: When I applied for WIC… READ FIRST THREE OPTIONS IN LIST

• 1=I was pregnant GO TO 3A

• 2=I had recently given birth (had an infant less than 1 year old) GO TO 3B

• 3=My pregnancy had recently ended due to a miscarriage or another reason GO TO 3C

• 4=BOTH RECENT BIRTH AND PREGNANT GO TO 3F

• 5=BOTH RECENT PREGNANCY ENDED AND PREGNANT SELECT 1=“I WAS PREGNANT”

• 6=BOTH RECENT BIRTH AND RECENT PREGNANCY ENDED GO TO 3F

• 7=NONE OF THE ABOVE SKIP TO INCOME ELIGIBILITY MODULE

• 9=DON’T RECALL SKIP TO NEXT INCOME ELIGIBILITY MODULE

3A. “When you applied for WIC on [APP_DATE], did you tell the WIC clinic that you were pregnant or that you thought you might be pregnant?”

• YES SKIP TO NEXT INCOME ELIGIBILITY MODULE

• NO SKIP TO NEXT INCOME ELIGIBILITY MODULE

• DON’T RECALL SKIP TO NEXT INCOME ELIGIBILITY MODULE

3B. “When was your baby born?”

ENTER DATE OF BIRTH:

mm-dd-yyyy

CAPI WILL DETERMINE INFANT AGE ON APP_DATE.

• IF (APP_DATE > LAST DAY OF MONTH INFANT TURNS 6 MONTHS) AND (APP_DATE ≤ LAST DAY OF MONTH OF INFANT’S FIRST BIRTHDAY), CAPI WILL GO TO 3D.

• IF (APP_DATE ≤ LAST DAY OF MONTH INFANT REACHES 6 MONTHS), CAPI WILL GO TO NEXT MODULE (ELIGIBLE AS POSTPARTUM OR BREASTFEEDING )

• IF APP_DATE > LAST DAY OF MONTH OF INFANT’S FIRST BIRTHDAY, CAPI WILL GO TO NEXT MODULE (NOT ELIGIBLE AS POSTPARTUM OR BREASTFEEDING.¹

3C. “[IF APPROPRIATE: I’m so sorry for your loss.] Some women can remain eligible for WIC for a certain period of time after a pregnancy ends. I’d like to ask you a couple of questions that may be upsetting to you.  You can tell me you don’t want to answer these questions and I’ll skip ahead to a different section of the interview.  Would it be ok if I asked you a couple of questions about the end of your pregnancy? ”

• YES GO TO 3CA

• NO SKIP TO INCOME ELIGIBILITY MODULE

3CA. Can you tell me when your pregnancy ended?”

ENTER DATE LAST PREGNANT:	mm/dd/yyyy		GO TO NEXT MODULE
IF UNSURE OF DATE, “Ok, which of the following is your best guess for when your pregnancy ended:” READ LIST
more than 6 months before [APP_DATE]
about 6 months before [APP_DATE] about 5 months before [APP_DATE]
about 4 months before [APP_DATE]
about 3 months before [APP_DATE]
about 2 months before [APP_DATE]
about 1 month before [APP_DATE]
within the 30 days prior to [APP_DATE]			GO TO NEXT MODULE

3D. “Thinking back to [APP_DATE], were you feeding your baby breastmilk once a day or more on average?”

• YES GO TO NEXT MODULE

• NO GO TO NEXT MODULE

• Don’t recall GO TO 3E

3E. “Let me see if I can help you remember. When you applied for WIC on [APP_DATE], your baby was [AGE: MONTHS] old. Were you feeding your baby breastmilk once a day or more often at that time?”

• YES GO TO NEXT MODULE

• NO GO TO NEXT MODULE

• Don’t recall GO TO NEXT MODULE

• IF APP_DATE > LAST DAY OF MONTH OF INFANT’S FIRST BIRTHDAY, GO TO NEXT MODULE (NOT ELIGIBLE AS POSTPARTUM OR BREASTFEEDING).

• IF (APP_DATE > LAST DAY OF MONTH INFANT TURNS 6 MONTHS) AND (APP_DATE ≤ LAST DAY OF MONTH OF INFANT’S FIRST BIRTHDAY) AND (3D=YES OR 3E=YES), ELIGIBLE AS BREASTFEEDING.

• IF (APP_DATE > LAST DAY OF MONTH INFANT TURNS 6 MONTHS) AND (APP_DATE ≤ LAST DAY OF MONTH OF INFANT’S FIRST BIRTHDAY) AND (3D=NO OR 3E=NO OR 3E=DON’T RECALL), THEN GO TO NEXT MODULE (NOT ELIGIBLE AS BREASTFEEDING OR POSTPARTUM)

3F. “Some women can remain eligible for WIC for a certain period of time after a pregnancy ends. I’d like to ask you a couple of questions that may be upsetting to you.  You can tell me you don’t want to answer these questions and I’ll skip ahead to a different section of the interview.  Would it be ok if I asked you a couple of questions about the end of your pregnancy and your recent birth? 

• YES GO TO 3FA

• NO SKIP TO INCOME ELIGIBILITY MODULE [FI: PROMPT JUST FOR DATE OF BIRTH, BUT NOT END OF PREGNANCY IF APPROPRIATE]

3FA. Ok, I need to know which happened first, you gave birth or you had a recent pregnancy end.

(i) “First, when was your baby born?”	mm-dd-yyyy	CAPI CALCULATES INFANT AGE ON APP_DATE
(ii) “And when did your recent pregnancy end?”	mm-dd-yyyy	CAPI CALCULATES WHICH EVENT FIRST
(iii) “Finally, were you feeding your baby breastmilk when you applied for WIC on [APP_DATE]? Your baby was [MONTHS] old then.”	YES NO Don’t recall	LOCAL AGENCY CAN EXTEND CERTIFICATION UP TO 30 DAYS FOR BREASTFEEDING WIC PARTICIPANT

IF INFANT BORN AFTER [APP_DATE] SELECT Q3=1 (PREGNANT) AND FOLLOW SKIP LOGIC TO 3A

IF INFANT BORN BEFORE [APP_DATE] AND APP_DATE ≤ LAST DAY OF MONTH INFANT REACHED 6 MOS OF AGE, GO TO NEXT MODULE (CATEGORICALLY ELIGIBLE AS EITHER BREASTFEEDING OR POSTPARTUM)

IF INFANT BORN BEFORE [APP_DATE] AND APP_DATE ≤ LAST DAY OF MONTH OF INFANT’S 1^ST BIRTHDAY AND APP_DATE > DATE INFANT REACHED 6 MOS OF AGE AND 3F(iii)=YES, was breastfeeding, CATEGORICALLY ELIGIBLE. GO TO NEXT MODULE

IF INFANT BORN BEFORE [APP_DATE] AND APP_DATE ≤ LAST DAY OF MONTH OF INFANT’S 1^ST BIRTHDAY AND APP_DATE > DATE INFANT REACHED 6 MOS OF AGE AND (3F(iii)=NO, not breastfeeding OR 3F(iii)=DON’T RECALL), CATEGORICALLY INELIGIBLE. GO TO NEXT MODULE

IF INFANT BORN BEFORE [APP_DATE] AND APP_DATE > LAST DAY OF MONTH OF INFANT’S 1^ST BIRTHDAY, CHECK DATE_PREG_END (this WIC participant has a child older than 1 year but also recently had a pregnancy end):

IF (DATE_PREG_END ≤ APP_DATE) AND (APP_DATE ≤ LAST DAY OF MONTH OF 6^TH MONTH AFTER DATE_PREG_END), CATEGORICALLY ELIGIBLE (POSTPARTUM): GO TO NEXT MODULE

IF (DATE_PREG_END ≤ APP_DATE) AND APP_DATE > LAST DAY OF MONTH OF 6^TH MONTH AFTER DATE_PREG_END), CATEGORICALLY INELIGIBLE: GO TO NEXT MODULE

IF DATE_PREG_END AFTER APP_DATE SELECT Q3=1 (PREGNANT) AND FOLLOW SKIP LOGIC TO 3A. IF 3A=YES, eligible as PREGNANT

INCOME ELIGIBILITY

HOUSEHOLD ENUMERATION

Q1“Next, I’m going to ask questions to understand your family situation, that is, your family size and income. Please tell me the names of all the people who were living or staying with you on in [MONTH OF APP_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 APP_DATE].”

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

1. [Q1 cont’d] 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=self
NAME OF WIC APPLICANT				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

Q1A. “Other than people already listed, is there anyone who typically lived with you but who was temporarily away in [MONTH OF APP_DATE]?” (IF NECESSARY, PROBE: “For example, this could be a military service member on active deployment, someone who was in the hospital, a child away at school, or a child who lived part-time with each parent. Is there anyone who typically lived here but who was temporarily away?”

• Yes GO TO MEMBERS TEMPORARILY AWAY

• No GO TO CHILDREN IN TEMPORARY CARE

1. [CONT’D] 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 in [MONTH OF APP_DATE]?” 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 AS PART OF 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. Thinking back to [MONTH OF APP_DATE], did this apply to any of the children you’ve listed? I’m going to read the names of each child who is 14 years old or younger. If you or your family were providing temporary care to that child in [MONTH OF APP_DATE], please answer ‘Yes.’”

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

“Were you, or was 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 APP_DATE].”

IF AGE ≥ 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF APP_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

• Don’t recall SELECT “SHARE LIKE FAMILY” FOR NAME

IF AGE < 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF APP_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

• Don’t recall SELECT “SHARE LIKE FAMILY” FOR NAME

PREFILLED					INTERVIEWER SELECTS
	Q1	Q2	Q3	Q4B	Q6
	NAME	GENDER	AGE	REASON TEMPORARILY AWAY	Family or Separate?2
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

FOR MEMBERS TEMPORARILY AWAY, PROBE IF NECESSARY:

• 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

IF PARTICIPANT CATEGORY ITEM 3=1 (PREGNANT ON APP_DATE) and 3A = Yes (WIC knew pregnant), CAPI WILL DISPLAY P1. ELSE, CAPI WILL GO TO P2

P1. “Earlier, you told me that you were pregnant when you applied for WIC on APP_DATE. At that time, were you expecting a single birth, twins, or more than twins?

• Singleton CAPI WILL ADD 1 TO FAMILY ECONOMIC UNIT

• Twins CAPI WILL ADD 2 TO FAMILY ECONOMIC UNIT

• Yes, with ENTER NUMBER CAPI WILL ADD [N] TO FAMILY ECONOMIC UNIT

P1A. Since that appointment have you given birth?” (DO NOT READ OPTIONS)

• YES                             GO TO P1B

• NO [STILL PREGNANT OR PREGNANCY ENDED]                        GO TO P2

P1B. “Have you already listed the infant/infants you gave birth to as part of your household above?” [CONFIRM THAT THE SAME NUMBER OF INFANTS FROM PREGNANCY (P1) 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 P2

P2. “Was another person in your family pregnant when you applied for WIC on APP_DATE? (IF NECESSARY: THESE QUESTIONS HELP DETERMINE THE CORRECT NUMBER OF PEOPLE IN YOUR HOUSEHOLD WHEN YOU APPLIED FOR WIC)

• Yes GO TO P3

• No GO TO CONFIRM SIZE OF FAMILY EU

P3. “Who was pregnant on APP_DATE?”
<SELECT NAME FROM Q1 LIST DROPDOWN MENU>	IF PREGNANT MEMBER SHARES FINANCES (Q6=1), GO TO P3A. IF PREGNANTMEMBER HAS SEPARATE FINANCES (Q6=2), GO TO CONFIRM SIZE OF FAMILY EU

P3A. “Was [NAME] expecting a single birth, twins or multiples?”

• Singleton IF SHARED FINANCES CAPI WILL ADD 1 TO FAMILY ECONOMIC UNIT

• Twins IF SHARED FINANCES CAPI WILL ADD 2 TO FAMILY ECONOMIC UNIT

• Yes, with ENTER NUMBER IF SHARED FINANCES CAPI WILL ADD [N] TO FAMILY ECONOMIC UNIT

P3B. “Since that appointment has [NAME] given birth?” (DO NOT READ OPTIONS)

• YES GO TO P3C

• NO [STILL PREGNANT OR PREGNANCY ENDED] GO TO P3D

P3C. “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 ITEM P3A 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 P3D

P3D. “Was anyone else pregnant on APP_DATE?” REPEAT P3-P3D AS NEEDED

CONFIRM 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 ANY FAMILY MEMBERS PREGNANT, EU_SIZE INCREMENTED BASED ON P1-P3 SERIES OF QUESTIONS

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

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

• IF Q6=2, THE INDIVIDUAL IS EXCLUDED FROM THE APPLICANT’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 on [APP_DATE], 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 on [APP_DATE], 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. “When you applied for WIC on [APP_DATE], were you, or a member of your family, participating in a benefits program such as Medicaid, SNAP, TANF or [NAME OF STATE PROGRAM(S)]?”

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
DON’T RECALL	GO TO INCOME SOURCES

PROOF SHOWN	NO PROOF SHOWN PROOF TOO NEW PROOF EXPIRED	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 APP_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]

PROOF TOO NEW

“It looks like this document was issued after you applied for WIC on [APP_DATE]. Do you have anything else from this program with an active date before APP_DATE?”

• YES CLICK TO ADD NEW DOCUMENT IN DOCUMENT PROOF

• NO “OK, thank you. Let’s move on to income sources.”

PROOF EXPIRED

“It looks like this document expired before you applied for WIC on [APP_DATE]. Do you have anything else from this program that shows you were an active on [APP_DATE]?”

• YES CLICK TO ADD NEW DOCUMENT IN DOCUMENT PROOF

• NO GO TO OTHER BENEFITS PROGRAM

OTHER BENEFITS PROGRAM

“Were you enrolled in any other benefits programs when you applied for WIC on [APP_DATE]?” [IF NECESSARY, PROMPT “such as Medicaid, SNAP, TANF or [NAME OF STATE PROGRAM(S) ]

• YES CLICK TO ADD NEW DOCUMENT IN DOCUMENT PROOF

• NO “OK, thank you. Let’s move on to income sources.” GO TO INCOME SOURCES

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 [APP_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 you and other members of your family were receiving when you applied for WIC on [APP_DATE]. The information you share will be combined with more than a thousand other people. Your name, address and other information that identifies you will not be included in study reports. We won’t share information about you with your local WIC agency, other benefit programs, your landlord, bank, employer, or people in your community.”

Q8a. At the time of your most recent certification appointment on [APP_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 [APP_DATE]? READ LIST:

• Less than 30 days before APP_DATE

• 1 month or longer before APP_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 application 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 APP_DATE. The FI will first attempt to obtain income documentation for a total of 30 days during the three months prior to APP_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 (based on the Identity or Residency modules), LACK OF DOCUMENTATION OF INCOME WILL NOT RESULT IN “INCOME INELIGIBLE” DETERMINATION.

Q9A. Thinking back to the 30 days before [APP_DATE], that is, between [APP_DATE-30] and [APP_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 9C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 as an option only if the Alternate Income Reference Period applies.

A. Thinking back to the 30 days before [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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.

INCOME DATE ROUTINE

IF INCOME PROOF DOCUMENT IS MORE THAN 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY PROBES:

DR1. “Were/was [you/NAME] receiving income from this source on APP_DATE?”

• YES GO TO DR2.

• NO GO TO DR4 (CAPI WILL EXCLUDE SOURCE).

• DON’T RECALL “OK, we’ll just assume things basically have stayed the same.” GO TO DR2

DR2. “Is this amount about the same as what [you/NAME] were/was receiving on APP_DATE?”

• YES SELECT DOCUMENT TYPE IN COLUMN C, ENTER AMOUNT SHOWN IN COLUMN D

• NO GO TO DR3

• DON’T RECALL “OK, we’ll just use this.” SELECT DOCUMENT TYPE IN COLUMN C, ENTER AMOUNT SHOWN IN COLUMN D

DR3. “What amount were/was [you/NAME] receiving when you applied for WIC on APP_DATE?”

SELECT “NONE: SELF-REPORT” IN COLUMN C AND ENTER AMOUNT REPORTED IN COLUMN D. GO DR4.

DR4. “Were/was [you/NAME] receiving any other income from [INCOME_TYPE] on APP_DATE?

• YES CAPI WILL OPEN NEW ROW OF THE SAME INCOME TYPE IN Q9

• NO CAPI WILL GO TO NEXT INCOME SOURCE IN Q9

• DON’T RECALL CAPI WILL GO TO NEXT INCOME SOURCE IN Q9

ZERO INCOME REPORTED

IF APPLICANT’S TOTAL FAMILY INCOME =$0 AND NO ADULT AGED ≥ 15 WITH SEPARATE FINANCES REPORTED, CAPI WILL DISPLAY INTRO AND Z1b-Z2. IF APPLICANT’S TOTAL FAMILY INCOME =$0 AND ANY ADULT AGED ≥ 15 WITH SEPARATE FINANCES REPORTED, CAPI WILL DISPLAY ALL ITEMS.

INTRO: “If I understand your answers correctly, it looks like you had zero income on [APP_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 [APP_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 [APP_DATE], that is, between [APP_DATE-30] and [APP_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 APP_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 receive payment until after [MONTH, YEAR OF APP_DATE] (IF NECESSARY: such as Temporary Assistance to Needy Families, sometimes called welfare, or SNAP/Food Stamps).	REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, PUBLIC ASSISTANCE
I had applied for workers compensation but did not receive payment until after [MONTH, YEAR OF APP_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 APP_DATE REVIEWED.

IF PRELIM_INCOME_ELIG=NO, THEN CAPI WILL SKIP TO END OF DENIED APPLICANTS SURVEY.

IF PRELIM_INCOME_ELIG= YES, 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 application appointment at WIC.”

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

	YES	NO
Let’s start with you [WIC APPLICANT]: was your income during the month before [APP_DATE] lower than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period lower than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period lower than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period lower 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 under-estimated your family’s typical income.”

10A. “I’d like you now to think back about three months before [APP_DATE]: So, I’m talking about [MONTH EQUAL TO MONTH OF APP_DATE‒90 DAYS] to [MONTH EQUAL TO MONTH OF APP_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 3RD MONTH BEFORE APP_DATE, REQUEST DOCUMENTATION FOR 2ND MONTH BEFORE APP_DATE;

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

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

IF NO DOCUMENTATION FOR 5TH MONTH BEFORE APP_DATE, REQUEST DOCUMENTATION FOR 6TH MONTH BEFORE APP_DATE. IF NONE, END LOOP [DO NOT REQUEST DOCUMENTATION OLDER THAN 6 MONTHS PRIOR TO APP_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 SURVEY

“Ok, this completes our survey. It was great talking with you, and thank you so much for helping us out.” .

IF PRELIMINARY RESULT = POSSIBLY ELIGIBLE:

“Because this is a research study, it will have no effect on the decision that WIC made. However, based on what you’ve told me, you may wish to re-apply for WIC, in case the agency made a mistake or your circumstances have changed since you last applied.”

IF PRELIMINARY RESULT = NOT ELIGIBLE:

“Because this is a research study, it will have no effect on the decision that WIC made. It looks like you were not eligible for WIC when you applied. However, in case your circumstances have changed since then, you may wish to re-apply.”

SEE BELOW FOR MILITARY PAY MODULE AND INCOME PROBE QUESTIONS MODULE.

MILITARY PAY MODULE³

PROMPT FOR MILITARY LEAVE AND EARNINGS STATEMENT AS CLOSE TO APP_DATE AS POSSIBLE. IF MORE THAN 30 DAYS BEFORE OR AFTER APP_DATE, GO TO INCOME DATE ROUTINE.

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:

“Did [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
Did [NAME] receive this pay in addition to the base pay?		
Was this pay the result of deployment to a designated combat zone?		
Did [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 INCOME4 “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.5
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 COSTS6
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.7
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 8
Volunteer, AmeriCorps, VISTA	“Was this income you received as a volunteer for AmeriCorps, AmeriCorps VISTA or AmeriCorps National Civilian Community Corps (NCCC)?”9
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 SOURCES10
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 CLAIM11
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 PAYMENTS12
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)13

Denied Applicant Survey: Version B (Infant/Child)

The NSWP-III Denied Applicant Survey has two similar versions. This is Version B. Version B is used when the applicant was applying on behalf of 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 applicant was a woman who was applying for WIC benefits for herself.

Instructions for Reviewers

The Denied Applicant 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 FI 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 applicant sampled for the Denied Applicant Survey; these data elements appear in Table 2 on the next page.

The NSWP-III version of the Denied Applicant Survey is similar in many aspects to the Certification Survey: it includes items needed to make an independent assessment of an applicant’s eligibility under four criteria: proof of identity; proof of residency; categorical eligibility; and income eligibility. However, the Denied Applicant Survey differs substantially from the version used in NSWP-II. The version fielded in NSWP-II was a brief telephone survey that relied heavily on self-report, and no documentation. For example, respondents were asked whether they knew the reason WIC had denied their application and, if so, whether they agreed with WIC’s determination of their ineligibility.

The survey is organized into the following modules:

Table 1: Denied Applicant 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 Applicant in the Sample
Variable	Description
APPLICANT	Name of denied WIC applicant (Last, First, Middle)
CAREGIVER	Name of adult (parent or caregiver) if APPLICANT is infant or child
ADDRESS	Applicant’s address (number, street, apartment number, city, state, zip code)
STATE	Applicant listed in this State’s denied applicant data or in a local agency’s denied applicant data within this State
STATE_ID	State WIC Agency identifier
LOCAL_ID	Local WIC Agency identifier
CLINIC_ID	Local clinic identifier
ITO	Yes/No, denied applicant is from an ITO or an LWA run by an Indian organization or Indian Health Service
APP_CAT	Applicant’s category (as assigned by WIC, if eligible as member of one of the five participant categories: P=pregnant; B=breastfeeding; N=not breastfeeding postpartum; INF=infant; C=child
APP_DATE	Date of most recent certification appointment
ADJUNCT_CK	Yes/No, local agency checked Medicaid, TANF, SNAP program enrollment to see if applicant was adjunctively income eligible
AUTO_CK	Yes/No, local agency checked State-specific program enrollment to see if applicant was automatically income eligible by WIC
MIGRANT	Yes/No, applicant 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	If applicant was pregnant on APP_DATE, number of expected live births if SINGLETON, PREG_NUM=1; if TWINS, PREG_NUM=2; etc.
ID_PROOF	Yes/No, applicant showed valid proof of ID
R_PROOF	Yes/No, applicant showed valid proof of residency
INC_PROOF	Yes/No, applicant showed valid proof of income
INCOME	Total income of the applicant’s economic unit, as determined by WIC on APP_DATE
D_REASON	Reason applicant ineligible for WIC

Denied Applicant Survey (Version B: Infant or Child)

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

Applicant Last­_Name				Applicant First_Name		Applicant Category			Application Date (APP_DATE)	Prior WIC Participant?	Applicant was Migrant?
Doe				Jane		P/B/N/INF/C/ or NONE: NOT CATEGORICALLY ELIGIBLE			mm/dd/yy	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	Applied for WIC in which State:		ST	Applied in which LWA:		Local Agency in which applicant applied
Family (EU) Size			#	Adjunct/Auto Elig?		Y/N	Adjunctive program name:
ITO?			Yes/No	Alternate income procedure?			Yes/No
IF APPLICANT 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. As you know, we are conducting this survey among people who were turned down for WIC benefits so that we can see if the agency is following correct procedures. We will keep your responses private to the extent allowed by law. Because the interview is private, it cannot change the decision made by WIC. However, if it appears that the local WIC agency may have made a mistake, or if your circumstances have changed since you last applied, you may want to apply for WIC benefits for your infant or child again.

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

Just to be sure we are both on the same page, I am going to be asking questions about the day you applied for WIC on [APP_DATE], on behalf of your infant or child.

1. “The first question about is identification. Thinking back to [APP_DATE] when you applied for WIC, did the WIC clinic ask you to show some form of identification for your child or for yourself?”

• YES, FOR CHILD GO TO 1A

• YES, FOR ME GO TO 1A

• BOTH GO TO 1A

• NO GO TO 1C

• DON’T RECALL GO TO 1C

1A.“What forms of identification did you show when you applied for WIC on [APP_DATE]?” [IF APPLICANT HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF ID FROM LIST.]

• MARK ID SHOWN AT WIC GO TO 1B

• DIDN’T SHOW ANY GO TO 1C

• DON’T RECALL GO TO 1C

1B. “Can you show me that same form of identification, or some other type of ID?” GO TO NEXT MODULE

1C. “Can you show me some ID now?” ENTER ID TYPE SHOWN NOW. GO TO 1D

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 or ID w/photo & name							
OTHER: specify ID shown AT WIC: DURING SURVEY:							
FI Notes			FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE

1D. “Was there any reason you were unable to show ID when you applied for WIC on APP_DATE?” DO NOT READ LIST.

 FORGOT TO BRING IT GO TO 1E

 DIDN’T HAVE ANY (PROBE: “Why didn’t you have any ID then?”) GO TO 1E

 DIDN’T KNOW WHAT ID TO BRING GO TO 1E

 THOUGHT I NEEDED DRIVER’S LICENSE, DIDN’T HAVE ONE GO TO 1E

 ID WAS STOLEN GO TO 1E

 HOMELESS GO TO 1E

 LOST MY WALLET/PURSE/ID GO TO 1E

 LOST ID IN A FIRE, FLOOD, OTHER DISASTER GO TO 1E

 WAS EVICTED AND LOST MY ID, OTHER PROPERTY GO TO 1E

 LEFT PARENTS’/PARTNER’S HOME /NO ACCESS TO ID GO TO 1E

 OTHER (SPECIFY: ) GO TO 1E

 NONE OF THE ABOVE GO TO 1E

 DON’T RECALL GO TO 1E

1E. “Did you go back to the WIC clinic sometime after [APP_DATE] with identification?

• YES

• NO

1F. “Do you, or does anyone in your household, work on farms and move from place to place as the season changes?”

• YES (MIGRANT FARMWORKER) GO TO NEXT MODULE

• NO GO TO NEXT MODULE

RESIDENCY: GEOGRAPHIC STATE

IF APPLICANT IN ITO OR LIVES IN INDIAN VILLAGE OR PUEBLO, 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. “Thinking back to [APP_DATE], when you applied for WIC, did the agency ask you to show something with you and your child’s home address to prove where you live?”

• YES GO TO 2A

• NO GO TO 2C

• DON’T RECALL GO TO 2C

2A. “What did you show that had your home address?” [IF R. HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF RESIDENCY PROOF FROM LIST. MAIL MUST HAVE RESIDENTIAL ADDRESS. P.O. BOX DOES NOT = PROOF OF RESIDENCY. RURAL ROUTE BOX NUMBER IS ACCEPTABLE RESIDENTIAL ADDRESS].

• MARK TYPE OF PROOF SHOWN AT WIC GO TO 2B

• DIDN’T SHOW ANY GO TO 2C

• DON’T RECALL GO TO 2C

2B. “Can you show me that same document or something else with your name and home address?” GO TO NEXT MODULE

2C. “Can you show me something with your home address now?” ENTER TYPE OF PROOF SHOWN NOW. GO TO 2D

Residency proofs	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:		

2D. “Was there any reason you were unable to show proof of where you and your child lived when you applied for WIC on [APP_DATE]?” DO NOT READ LIST.

 FORGOT TO BRING IT GO TO 2E

 DIDN’T HAVE ANY (PROBE: “Why didn’t you have any ID then?”) GO TO 2E

 DIDN’T KNOW WHAT TO BRING GO TO 2E

 THOUGHT I NEEDED DRIVER’S LICENSE, DIDN’T HAVE ONE GO TO 2E

 WAS STOLEN GO TO 2E

 HOMELESS GO TO 2E

 LOST MY WALLET/PURSE/ID GO TO 2E

 LOST IN A FIRE, FLOOD, OTHER DISASTER GO TO 2E

 WAS EVICTED AND LOST MY BELONGINGS GO TO 2E

 LEFT PARENTS’/PARTNER’S HOME/NO ACCESS TO PROOF GO TO 2E

 OTHER (SPECIFY: ) GO TO 2E

 NONE OF THE ABOVE GO TO 2E

 DON’T RECALL

2E. “Did you go back to the WIC clinic sometime after [APP_DATE] with something proving where you and your child lived?

• YES

• NO

2F.: “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 NEXT MODULE

• NO GO TO NEXT MODULE

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

ALTERNATE PROCEDURE APPLIES ONLY IF APPLICANT FROM ITO OR LIVES IN INDIAN VILLAGE OR PUEBLO 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.

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 lived at the time of your application appointment?

• 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

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

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

CAPI WILL CALCULATE THE APPLICANT’S AGE AS OF APP_DATE TO DETERMINE WHETHER THE APPLICANT QUALIFIED AS AN INFANT OR CHILD

THE APPLICANT COULD HAVE QUALIFIED AS INFANT IF A OR B WAS TRUE ON APP_DATE:

1. THE APPLICANT WAS ≤ 12 MONTHS ON APP_DATE, OR

2. THE APPLICANT’S APP_DATE FELL ON OR BETWEEN THE BIRTHDATE + 1 YEAR AND THE LAST DAY OF THE MONTH IN WHICH THE APPLICANT REACHED 1 YEAR OF AGE. EXAMPLE:

John Doe was born on April 2, 2016. John Doe has never received WIC before. The most recent application date was April 10, 2017 and he could have been 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.)

THE APPLICANT COULD HAVE QUALIFIED AS A CHILD IF A OR B OR C WAS TRUE ON APP_DATE:

1. THE APPLICANT WAS ≤ 60 MONTHS AND > 12 MONTHIS ON APP_DATE, OR

2. THE APPLICANT’S APP_DATE FELL ON OR BETWEEN THE BIRTHDATE + 60 MONTHS AND THE LAST DAY OF THE MONTH IN WHICH THE APPLICANT REACHED 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 APPLICANT WAS < 12 MONTHS AND THE APP_DATE FELL ON OR BETWEEN THE LAST DAY OF THE MONTH IN WHICH THE APPLICANT TURNED 11 MONTHS OF AGE AND THE BIRTHDATE + 1 YEAR. EXAMPLE:

Jane Doe was born on 12-25-16 and Jane’s mother was having difficulty scheduling an appointment to apply for WIC for Jane. Her local WIC agency suggests that she come to an appointment for Jane on 12-02-17. On that date, the agency could have determined that Jane was eligible as a CHILD even though Jane was only 11 months, 7 days old. The agency has discretion to shorten an infant certification period by up to 30 days (i.e., to December 1, 2017) or extend the child certification by this same amount. Jane was less than 12 months of age on her application date but the application date was between the last day of the month in which she turned 11 months (November 30) and her first birthday.

INCOME ELIGIBILITY

HOUSEHOLD ENUMERATION

Q1 “Next, I’m going to ask questions to understand your family situation, that is, your family size and income. Please tell me the names of all the people who were living or staying with [NAME OF SAMPLED INFANT/CHILD] in [MONTH OF APP_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 APP_DATE]..”

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

1. [Q1 cont’d] 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

Q1A. “Other than people already listed, was there anyone who typically lived with you and your child, but who was temporarily away in [MONTH OF APP_DATE]?” (IF NECESSARY, PROBE: “For example, this could be a military service member on active deployment, someone who was in the hospital, a child who was away at school, a child who lived part-time with each parent. Is there anyone who typically lived here but who was temporarily away?”

• Yes GO TO MEMBERS TEMPORARILY AWAY

• No GO TO CHILDREN IN TEMPORARY CARE

1. [CONT’D] 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 in [MONTH OF APP_DATE]?” 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 APP_DATE]

Members temporarily away
Q1A	Q2A	Q3A	Q4A	Relationship Codes		Q4B	Q4C
NAME	GENDER	AGE	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	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. Thinking back to [MONTH OF APP_DATE], did this apply to any of the children (other than [NAME OF SAMPLED INFANT/CHILD]) you’ve listed? I’m going to read the names of each child who is 14 years old or younger. If you or your family were providing temporary care to that child in [MONTH OF APP_DATE], please answer ‘Yes.’”

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

“Were you, or was 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 APP_DATE].”

IF AGE ≥ 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OFAPP_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

• Don’t recall SELECT “SHARE LIKE FAMILY” FOR NAME

IF AGE < 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF APP_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

• Don’t recall SELECT “SHARE LIKE FAMILY” FOR NAME

PREFILLED					INTERVIEWER SELECTS
	Q1	Q2	Q3	Q4B	Q6
	NAME	GENDER	AGE	REASON TEMPORARILY AWAY	Family or Separate?14
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

FOR MEMBERS TEMPORARILY AWAY, PROBE IF NECESSARY:

• 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 another person in [NAME OF INFANT/CHILD]’s family pregnant when you applied for WIC on APP_DATE?

• 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 CONFIRM SIZE OF FAMILY EU

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

• TWINS IF SHARED FINANCES CAPI WILL ADD 2 TO FAMILY ECONOMIC UNIT

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

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 ITEM P2A 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 APP_DATE?” REPEAT P2-P2D AS NEEDED

CONFIRM 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 ANY FAMILY MEMBERS PREGNANT, EU_SIZE INCREMENTED BASED ON P1-P3 SERIES OF QUESTIONS

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

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

• IF Q6=2, THE INDIVIDUAL IS EXCLUDED FROM THE APPLICANT’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. “When you applied for WIC on [APP_DATE], was your child, or another member of his/her family, participating in a benefits program such as Medicaid, SNAP, TANF or [NAME OF STATE PROGRAM(S)]?”

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/MY CHILD’S 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
DON’T RECALL	GO TO INCOME SOURCES

PROOF SHOWN	NO PROOF SHOWN PROOF TOO NEW PROOF EXPIRED	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 APPLICANT’s NAME:	If program is SNAP or FDPIR and NAME on document is member of APPLICANT’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 APPLICANT’s family (Q6=shared), then acceptable proof. If program is TANF and NAME on document is a member of APPLICANT’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 APP_DATE Other:

CAPI WILL GO TO INCOME SOURCES EVEN IF ADJUNCTIVELY/AUTOMATICALLY INCOME ELIGIBLE: [Note for reviewers: Regardless of adjunctive income eligibility status, for denied applicants we will also collect income in case information about adjunctive eligibility is invalid after post-field review.]

PROOF TOO NEW

“It looks like this document was issued after you applied for WIC on [APP_DATE]. Do you have anything else from this program with an active date before APP_DATE?”

• YES CLICK TO ADD NEW DOCUMENT IN DOCUMENT PROOF

• NO “OK, thank you. Let’s move on to income sources.”

PROOF EXPIRED

“It looks like this document expired before you applied for WIC on [APP_DATE]. Do you have anything else from this program that shows you were/your child was an active participant on [APP_DATE]?”

• YES CLICK TO ADD NEW DOCUMENT IN DOCUMENT PROOF

• NO GO TO OTHER BENEFITS PROGRAM

OTHER BENEFITS PROGRAM

“Were you or your child enrolled in any other benefits programs when you applied for WIC on [APP_DATE]?” [IF NECESSARY, PROMPT “such as Medicaid, SNAP, TANF or [NAME OF STATE PROGRAM(S)]”]

• YES CLICK TO ADD NEW DOCUMENT IN DOCUMENT PROOF

• NO “OK, thank you. Let’s move on to income sources.” GO TO INCOME SOURCES

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 [APP_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 you and other members of your family were receiving when you applied on [APP_DATE] for your child to receive WIC. The information you share will be combined with more than a thousand other people. Your name, your child’s name, address and other information that identifies you will not be included in study reports. We won’t share information about you or your family with your local WIC agency, other benefit programs, your landlord, bank, employer, or people in your community.”

Q8a. When you applied for WIC on [APP_DATE], were you or someone in your family unemployed – that is, had you or another family member been working but stopped?

• Yes GO TO Q8b

• No GO TO INCOME SOURCES

Q8b. About how long had this person been unemployed as of [APP_DATE]? READ LIST:

• Less than 30 days before APP_DATE

• 1 month or longer before APP_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 application 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 APP_DATE. The FI will first attempt to obtain income documentation for a total of 30 days during the three months prior to APP_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 [APP_DATE], that is, between [APP_DATE-30] and [APP_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 9C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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 [APP_DATE], 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”]. IF DOCUMENT IS > 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY INCOME DATE ROUTINE

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.

INCOME DATE ROUTINE

IF INCOME PROOF DOCUMENT IS MORE THAN 30 DAYS BEFORE OR AFTER APP_DATE, CAPI WILL DISPLAY PROBES:

DR1. “Were/was [you/NAME] receiving income from this source on APP_DATE?”

• YES GO TO DR2.

• NO GO TO DR4 (CAPI WILL EXCLUDE SOURCE).

• DON’T RECALL “OK, we’ll just assume things basically have stayed the same.” GO TO DR2

DR2. “Is this amount about the same as what [you/NAME] were/was receiving on APP_DATE?”

• YES SELECT DOCUMENT TYPE IN COLUMN C, ENTER AMOUNT SHOWN IN COLUMN D

• NO GO TO DR3

• DON’T RECALL “OK, we’ll just use this.” SELECT DOCUMENT TYPE IN COLUMN C, ENTER AMOUNT SHOWN IN COLUMN D

DR3. “What amount were/was [you/NAME] receiving when you applied for WIC on APP_DATE?”

SELECT “NONE: SELF-REPORT” IN COLUMN C AND ENTER AMOUNT REPORTED IN COLUMN D. GO DR4.

DR4. “Were/was [you/NAME] receiving any other income from [INCOME_TYPE] on APP_DATE?

• YES CAPI WILL OPEN NEW ROW OF THE SAME INCOME TYPE IN Q9

• NO CAPI WILL GO TO NEXT INCOME SOURCE IN Q9

• DON’T RECALL CAPI WILL GO TO NEXT INCOME SOURCE IN Q9

ZERO INCOME REPORTED

IF APPLICANT’S TOTAL FAMILY INCOME =$0 AND NO ADULT AGED ≥ 15 WITH SEPARATE FINANCES REPORTED, CAPI WILL DISPLAY INTRO AND Z1b-Z2. IF APPLICANT’S TOTAL FAMILY INCOME =$0 AND ANY ADULT AGED ≥ 15 WITH SEPARATE FINANCES REPORTED, CAPI WILL DISPLAY ALL ITEMS.

INTRO: “If I understand your answers correctly, it looks like you had zero income on [APP_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 [APP_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 [APP_DATE], that is, between [APP_DATE-30] and [APP_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 APP_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 receive payment until after [MONTH, YEAR OF APP_DATE] (IF NECESSARY: such as Temporary Assistance to Needy Families, sometimes called welfare, or SNAP/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 APP_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 APP_DATE REVIEWED.

IF PRELIM_INCOME_ELIG=NO, THEN CAPI WILL SKIP TO END OF DENIED APPLICANTS SURVEY.

IF PRELIM_INCOME_ELIG= YES, 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 application appointment at WIC.”

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

	YES	NO
Let’s start with you [WIC APPLICANT]: was your income during the month before [APP_DATE] lower than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period lower than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period lower than usual?		
NEXT MEMBER OF FAMILY ECONOMIC UNIT WITH NON-ZERO INCOME: Was [NAME’s] income during this period lower 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 under-estimated your family’s typical income.”

10A. “I’d like you now to think back about three months before [APP_DATE]: So, I’m talking about [MONTH EQUAL TO APP_DATE‒90 DAYS] to [MONTH EQUAL TO APP_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 3RD MONTH BEFORE APP_DATE, REQUEST DOCUMENTATION FOR 2ND MONTH BEFORE APP_DATE;

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

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

IF NO DOCUMENTATION FOR 5TH MONTH BEFORE APP_DATE, REQUEST DOCUMENTATION FOR 6TH MONTH BEFORE APP_DATE. IF NONE, END LOOP [DO NOT REQUEST DOCUMENTATION OLDER THAN 6 MONTHS PRIOR TO APP_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 SURVEY

“Ok, this completes our survey. It was great talking with you, and thank you so much for helping us out.”.

IF PRELIMINARY RESULT = POSSIBLY ELIGIBLE:

“Because this is a research study, it will have no effect on the decision that WIC made. However, based on what you’ve told me, you may wish to re-apply for WIC for your child, in case the agency made a mistake or your circumstances have changed since you last applied.”

IF PRELIMINARY RESULT = NOT ELIGIBLE:

“Because this is a research study, it will have no effect on the decision that WIC made. It looks like your child was not eligible for WIC when you applied. However, in case your circumstances have changed since then, you may wish to re-apply.”

SEE BELOW FOR MILITARY PAY MODULE AND INCOME PROBE QUESTIONS MODULE

MILITARY PAY MODULE¹⁵

PROMPT FOR MILITARY LEAVE AND EARNINGS STATEMENT AS CLOSE TO APP_DATE AS POSSIBLE. IF MORE THAN 30 DAYS BEFORE OR AFTER APP_DATE, GO TO INCOME DATE ROUTINE.

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:

“Did [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
Did [NAME] receive this pay in addition to the base pay?		
Was this pay the result of deployment to a designated combat zone?		
Did [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 applicant 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 INCOME16 “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 applicant 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.17
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 COSTS18
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.19
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 20
Volunteer, AmeriCorps, VISTA	“Was this income you received as a volunteer for AmeriCorps, AmeriCorps VISTA or AmeriCorps National Civilian Community Corps (NCCC)?”21
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 SOURCES22
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 CLAIM23
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 PAYMENTS24
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)25

1 Although local agencies may shorten or extend the certification period of a breastfeeding woman up to 30 days if there is difficulty scheduling a certification appointment, this is within the local agency’s discretion. The Denied Applicant Survey analysis will not attempt to determine whether a local agency should have exercised this discretion.

2 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.

3 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.”

4 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)).

5 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)

6 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)

7 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).

8 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).

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

10 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)

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

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

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

14 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.

15 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.”

16 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)).

17 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)

18 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)

19 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).

20 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).

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

22 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)

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

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

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