State WIC Agency Officials (2016 and 2018)

APPENDIX K:

Data Transmittal Worksheet

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

WORKSHEET FOR TRANSMITTING APRIL [STUDY YEAR] DATA FILES

WIC PARTICIPANT AND PROGRAM CHARACTERISTICS [STUDY YEAR]

April [STUDY YEAR] data submissions should be sent to [CONTRACTOR] as soon after April [STUDY YEAR] as possible, and no later than July 15, [STUDY YEAR]. However, States are urged to ensure that their data for April [STUDY YEAR] is complete. Thus, if States are expecting updated information on income, breastfeeding, participation, or other data fields, in the period after April [STUDY YEAR] , they should only submit their data after this information has been fully entered. Please include this completed worksheet with your April data submission.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

1. State _________________________________________________________________

2. Name, title, phone number, and fax number of person able to answer questions regarding State data submission. Please provide email address if available.

name

title

telephone fax

email

3. April data file:

a. Number of participant records ________________________________________

b. Maximum record length _____________________________________________

4. Is racial/ethnic data reported using the 3-digit code, the series of 6 yes/no questions, or some other format? check one answer below.

_____ 3-Digit code provided in guidance

_____ series of 6 yes/no questions

_____ Some other Format Describe__________________________________________

5. Breastfeeding data collection procedures:

a. When is breastfeeding data collected? check all that apply.

_____ at issuance

_____ at certification/recertification

_____ during health care appointments

_____ at nutrition education sessions

_____ separate telephone or mail inquiry

_____ other describe_________________________________________

_________________________________________________________

_________________________________________________________

b. Does your State collect breastfeeding data: check one answer.

_____ only on infants ages 6 to 13 months in april [STUDY YEAR]

_____ on infants ages 6 to 13 months when data are collected

_____ all infants

_____ other describe_________________________________________

_________________________________________________________

_________________________________________________________

c. Is breastfeeding data collected routinely or only for the biennial PC reporting?

circle one answer below.

routinely only for PC reporting

d. Does your State’s automated data system maintain the most recent breastfeeding information?

circle one answer below.

yes no

6. Please send food package code translations for types and amounts of WIC foods prescribed. Food package translations are— Circle one answer below.

Enclosed have been sent earlier will be sent under separate cover

7. Did you submit food code data using food package codes, an item/quantity format, or some other format? check one answer.

_____ Food Package Codes (up to 14 codes with no more than 10 digits per code)

_____ Item-Quantity Format

_____ Other Format (please provide format)

8. Is food package type reported using the specified codes 1 through 28, or some other format? check one answer.

_____ Used specified codes 1 through 28

_____ Other Format (please provide format)

9. Please check the Supplemental Dataset items submitted for PC[STUDY YEAR]. check all that apply.

_____ date of first wic certification

_____ education level

_____ number in household on wic

_____ date previous pregnancy ended

_____ total number of pregnancies

_____ total number of live births

_____ prepregnancy weight

_____ weight gain during pregnancy

_____ baby’s birth weight

_____ baby’s length at birth

_____ participation in food distribution on indian reservation program

10. Are Service Site IDs reported in the data? Circle one answer below.

yes no

11. Other special information.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Please send files and documentation to:

[CONTRACTOR ADDRESS]	[CONTRACTOR EMAIL]