APPENDIX B3.b
CERTIFICATION SURVEY VERSION B (INFANT/CHILD) - ENGLISH
The NSWP-III Certification Survey has two versions. This is Version B of the NSWP-III Certification Survey. Version B is used when the participant is an infant or child. The survey respondent for Version B is the adult applicant who sought WIC certification for the infant or child. Version A (included separately) is used when the sampled participant is a pregnant, breastfeeding or postpartum, non-breastfeeding woman.
The Certification Survey will be administered by trained Field Interviewers (FIs). After FNS approves the final draft, the research team will begin implementing the survey in a Computer Assisted Personal Interview (CAPI) format programmed for use on study laptops. This paper version approximates the layout of the CAPI questionnaire and includes notes indicating how the CAPI system will automatically route the interviewer to the appropriate questions or data entry forms, or performs specified calculations (these notes appear in the paper version in RED, CAPITALIZED text but will not appear on-screen in the CAPI version). In addition, the CAPI version will be programmed to pre-populate certain data about each participant sampled for the Certification Survey; these data elements appear in Table 2 on the next page.
The NSWP-III version of the Certification Survey is adapted from the version used in NSWP-II. This is motivated by an effort to minimize differences in data collection to allow meaningful comparison of the estimates of improper payment errors between the two studies. The survey is organized into the following modules:
Table 1: Certification Survey Modules |
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Name |
Purpose |
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Document proof of identity |
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Document proof of residency |
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For Infant or Child participants, confirm participant category |
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Determine the size of the participant’s family economic unit (SURVEY_EU_SIZE); Collect documentation of income sources |
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Thank participant and conclude survey |
FIs will administer the five numbered modules in order. Text that FIs read aloud (questions, response options where indicated) appear in regular text, while on-screen instructions to FIs appear in CAPITALIZED TEXT.
Table 2. Data Pre-Populated into the Computer-Assisted Personal Interview (CAPI) system for each Participant in the Sample |
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Variable |
Description |
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PARTICIPANT LAST NAME |
WIC participant’s last name |
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PARTICIPANT FIRST NAME |
WIC participant’s first name |
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DOB |
Date of birth of infant or child participant |
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CAREGIVER |
Name of Certification Survey applicant if PARTICIPANT is infant or child |
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STREET |
Street name and number (from WIC agency) |
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CITY |
City (from WIC agency) |
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STATE |
Participant listed in this State’s WIC participant data |
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ZIP |
Zip code (from WIC agency) |
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STATE_ID |
State WIC Agency identifier |
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LOCAL_ID |
Local WIC Agency identifier |
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CLINIC_ID |
Local clinic identifier |
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ITO |
Yes/No, Participant receives WIC from via ITO |
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CERT_CAT |
Participant’s category (as assigned by WIC) P=pregnant; B=breastfeeding; N=not breastfeeding postpartum; INF=infant; C=child |
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CERT_DATE |
Start date of most recent certification period |
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MONTH OF CERT_DATE |
Name of the month of most recent certification date (CAPI will calculate from CERT_DATE) |
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CERT_EXPIRES |
End date of certification period |
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CERT_PERIOD |
Number of days of most recent certification period (1 to 365) (CAPI will calculate using CERT_EXPIRES and CERT_DATE) |
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30 days 60 days 90 days 120 days |
1 month 2 months 3 months 4 months |
150 days 180 days 210 days 240 days |
5 months 6 months 7 months 8 months |
270 days 300 days 330 days 360+ days |
9 months 10 months 11 months 12 months |
ADJUNCT_ELIG |
Yes/No, Participant was certified as adjunctively (or automatically) income eligible by WIC |
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ADJUNCT_PROGRAM |
Name of program that made participant adjunctively (or automatically) income eligible |
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MIGRANT |
Yes/No, Participant is a migrant worker |
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Version B: Infant or Child WIC Participant
INTRO: Hi. Thanks for agreeing to do this survey. We will keep your answers private to the extent allowed by law. None of the information you share with me will cause your WIC benefits to change. The purpose of the survey is to help get a better idea of who participates in the program and their family’s circumstances. After we finish, I will give you a $25 Visa debit card to thank you for your participation. Before we start, we need to review this form together. It tells you about your rights as a study participant. It tells you how we will protect your privacy and how we will use your answers.
READ INFORMED CONSENT STATEMENT AND GET SIGNED CONSENT BEFORE PROCEEDING.
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 42 minutes (0.70 hours) 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.
The first thing we need is some identification for [NAME of INFANT/CHILD WIC PARTICIPANT]. [IF PARTICIPANT HAS TROUBLE WITH THIS REQUEST, READ OFF SOME OF THE ACCEPTABLE TYPES OF ID FROM LIST.]
Identification proofs [CHECK AT LEAST ONE] |
INFANT or CHILD ID shown during survey |
CAREGIVER ID (if no ID for infant/child) shown during survey |
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Birth certificate w/infant/child’s name |
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Hospital or immunization record, hospital ID bracelet w/infant/child’s name |
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U.S. or foreign passport w/photo and infant/child’s name |
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Social Security or Green card for infant/child (or other Immigration document with name) |
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Letter from government agency (including WIC) w/ infant/child’s name |
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WIC ID Card or WIC document with infant/child name (EBT cards are NOT valid proof of identity) |
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PARENT/GUARDIAN ONLY: Work, school, military, or bus pass ID w/photo & name |
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PARENT/GUARDIAN ONLY: Driver’s license w/photo & name |
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State- or tribal- issued license of ID w/photo & name |
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OTHER (SPECIFY): |
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FI Notes |
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FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE |
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1A. DOES NAME ON ID MATCH SAMPLE INFORMATION?
YES MARK ID SHOWN DURING SURVEY
NO “The name on this ID doesn’t match my records. Can you show me another form of ID that has your child’s name?”
NO VALID IDENTIFICATION “Ok, do you have any ID for yourself?”
YES MARK TYPE OF CAREGIVER ID IN TABLE AND GO TO 1B.
NO GO TO 1B.
1B. “Was your ID, or records having to do with your child’s recently stolen, did you recently lose your ID or your child’s records? Have you and your child recently been homeless, or experienced a fire, flood, hurricane, tornado, or similar event?”
STOLEN/LOST GO TO 1C
HOMELESS GO TO 1C
DISASTER VICTIM GO TO 1C
{Other, State-specific reason that providing ID is unreasonable burden} GO TO 1C
NONE OF THE ABOVE GO TO 1C
1C. “At your recent WIC certification appointment on or before CERT_DATE, did you show any identification for [NAME OF INFANT/CHILD WIC PARTICIPANT] then?” (IF YES: Do you recall what type of ID you showed?) CHECK BOTH WHETHER ID FOR CHILD AND FOR SELF SHOWN
SHOWED ID FOR CHILD AND RECALLS TYPE MARK ID SHOWN AT WIC AND GO TO NEXT MODULE
SHOWED ID FOR SELF AND RECALLS TYPE MARK ID SHOWN AT WIC AND GO TO NEXT MODULE
SHOWED ID FOR CHILD BUT NO RECALL OF TYPE GO TO NEXT MODULE
SHOWED ID FOR SELF BUT NO RECALL OF TYPE GO TO NEXT MODULE
DID NOT SHOW ID FOR EITHER GO TO NEXT MODULE
DO NOT RECALL GO TO NEXT MODULE
Note to reviewers: IF NO ID, LOCAL AGENCIES MAY ISSUE A TEMPORARY CERTIFICATION OF 30 DAYS OR LESS.
Identification proof shown at WIC agency |
INFANT OR CHILD ID Shown at WIC agency? (self-reported) |
CAREGIVER ID Shown at WIC agency? (self-reported) |
Birth certificate w/infant/child’s name |
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Hospital or immunization record, hospital ID bracelet w/infant/child’s name |
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U.S. or foreign passport w/photo and infant/child’s name |
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Social Security or Green card for infant/child (or other Immigration document with name) |
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Letter from government agency (including WIC) w/ infant/child’s name |
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WIC ID Card or WIC document with infant/child name (EBT cards are NOT valid proof of identity) |
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PARENT/GUARDIAN ONLY: Work, school, military, or bus pass ID w/photo & name |
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PARENT/GUARDIAN ONLY: Driver’s license w/photo & name |
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State- or tribal- issued license of ID w/photo & name |
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Other [SPECIFY] |
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IF PARTICIPANT OR CAREGIVER LIVES IN REMOTE INDIAN VILLAGE OR PUEBLO THEN CAPI WILL SKIP TO “ALTERNATE PROOF OF RESIDENCY.” ELSE CONTINUE WITH RESIDENCY: GEOGRAPHIC STATE PROCEDURE.
IF IDENTIFICATION SHOWN AS PROOF OF IDENTITY HAS ADDRESS AND IS AN ACCEPTED PROOF OF RESIDENCY, MARK OFF THE TYPE OF RESIDENCY PROOF IN TABLE BELOW AND SKIP TO INCOME ELIGIBILITY MODULE. OTHERWISE GO TO QUESTION 2.
INTRO:
“Next, I need some kind of proof that you live here. Do you have a utility bill, lease, or letter with your name and address?” MAIL MUST HAVE RESIDENTIAL ADDRESS AND DATE OR POSTMARK WITHIN 3 MONTHS OF CERT_DATE. P.O. BOX DOES NOT = PROOF OF RESIDENCY. RURAL ROUTE BOX NUMBER IS ACCEPTABLE RESIDENTIAL ADDRESS.
2. IS PROOF OF RESIDENCY CURRENT (NON-EXPIRED OR DATED/POSTMARKED WITHIN 3 MONTHS OF CERT_DATE)?
YES GO TO 2A
NOT CURRENT: “Do you have anything more recent? This document is too old.”
NO CURRENT PROOF OF RESIDENCY IF MIGRANT=YES OR UNKNOWN, GO TO 2C(i);
IF MIGRANT=NO, GO TO 2C(ii)
2A. DO NAME (OF EITHER INFANT OR CAREGIVER) AND ADDRESS MATCH SAMPLE INFORMATION?
YES MARK PROOF SHOWN DURING SURVEY AND GO TO NEXT MODULE
NAME IS DIFFERENT BUT ADDRESS MATCHES GO TO 2D
ADDRESS IS DIFFERENT BUT NAME MATCHES GO TO 2E
NAME AND ADDRESS ARE BOTH DIFFERENT GO TO 2E
Residency proofs [CHECK AT LEAST ONE] Recent means within 3 months of [MONTH_OF_CERT_DATE] |
Shown during survey |
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Recent utility bill (cableTV, electric/gas, water, sewer, garbage pickup) w/participant name & address |
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Recent rent/mortgage receipt or lease w/participant & address |
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Recent mail (letter and/or postmarked envelope) received w/participant & address |
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Current voter’s registration card w/participant’s name & address |
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[IF STATE ALLOWS] Current driver’s license, State or Tribal ID w/participant’s name and address |
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[OTHER STATE ALLOWED RESIDENCY PROOF] |
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Other: SPECIFY: |
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FI Notes |
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FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE |
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2C(i). (MIGRANT = YES OR UNKNOWN): “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 that include a migrant farmworker who moves around the country depending on where there is work based on the growing season.”
YES (MIGRANT FARMWORKER) GO TO 2F
NO GO TO 2C(ii)
2C(ii). (MIGRANT=NO): “Did you recently lose documents with your address or were they stolen? Have you and your child recently been homeless, or recently experienced a fire, flood, hurricane, tornado, or similar event?”
STOLEN/LOST GO TO 2F
HOMELESS GO TO 2F
DISASTER VICTIM GO TO 2F
{Other, State-specific reason that providing proof is unreasonable burden} GO TO 2F
NONE OF THE ABOVE GO TO 2F
2D. (ADDRESS MATCHES BUT NAME DIFFERS FROM INFANT OR CAREGIVER): “This has an address, but neither your name or your child’s name. Do you have something with your name and address (or your child’s name and address)?” READ LIST IN 2A FOR EXAMPLES OF OTHER TYPES OF DOCUMENTS FOR RESIDENCY PROOF.
YES MARK PROOF SHOWN DURING SURVEY AND GO TO NEXT MODULE
ADDRESS IS DIFFERENT BUT NAME MATCHES GO TO 2E
NAME AND ADDRESS ARE BOTH DIFFERENT GO TO 2E
NO CURRENT PROOF OF RESIDENCY IF MIGRANT = YES OR UNKNOWN, GO TO 2C(i); IF MIGRANT = NO, GO TO 2C(ii)
2E. (ADDRESS DIFFERS OR NAME AND ADDRESS DIFFER): “Ok, the [name and] address on this document doesn’t match my records.
Have you moved since CERT_DATE? Just as a reminder, WIC won’t know any personal information you share with me, including whether or not your address has changed.”
YES (RECENTLY MOVED) ENTER INFO BELOW AND GO TO 2F
NO (DID NOT RECENTLY MOVE) REVERSE TO 2C(i)
State: |
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ZIP: |
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ADDRESS IS A STREET ADDRESS (Not PO Box)? |
Yes No |
2F. “At your recent WIC certification appointment, did you show anything with your child’s or your name and address then?” (IF YES: “Do you recall what type of document you showed?”)
SHOWED PROOF AND RECALLS TYPE MARK PROOF SHOWN AT WIC AND GO TO NEXT MODULE
SHOWED PROOF BUT NO RECALL OF TYPE GO TO NEXT MODULE
DID NOT SHOW PROOF GO TO NEXT MODULE
DO NOT RECALL GO TO NEXT MODULE
Note to reviewers: IF NO ID, LOCAL AGENCIES MAY ISSUE A TEMPORARY CERTIFICATION OF 30 DAYS OR LESS.
Residency proofs |
Shown at WIC appointment (self-reported) |
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Utility bill (cableTV, electric/gas, water, sewer, garbage pickup) w/participant name & address |
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Rent/mortgage receipt or lease w/participant name & address |
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Mail (letter and/or postmarked envelope) received w/participant name & address |
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Voter’s registration card w/participant name & address |
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Driver’s license, State or Tribal ID w/participant name and address |
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Other: SPECIFY: |
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FI Notes |
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FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE |
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ALTERNATE PROCEDURE APPLIES ONLY IF PARTICIPANT LIVES ON TRIBAL LAND OR IN REMOTE INDIAN VILLAGE OR PUEBLO “ALTERNATE PROOF OF RESIDENCY PROCEDURE” APPLIES.ALTERNATIVE RESIDENCY PROCEDURE: GET VILLAGE NAME AND MAILING ADDRESS.
IF SAMPLE INFORMATION SHOWS A RESIDENTIAL STREET ADDRESS (NOT A PO BOX), GO TO ALT 2A.
IF SAMPLE INFORMATION SHOWS A PO BOX AND DO NOT SHOW VILLAGE, GO TO ALT 2B.
IF SAMPLE INFORMATION DOES NOT SHOW A PO BOX AND SHOW A VILLAGE, GO TO ALT 2B.
IF SAMPLE INFORMATION SHOWS A PO BOX AND A VILLAGE, GO TO ALT 2D.
ALT 2A. “Do you have a document with you or your child’s name and you and your child’s home address?”
YES ENTER PROOF BELOW
NO STREET ADDRESS, TRIBAL LAND OR REMOTE VILLAGE/PUEBLO GO TO ALT 2B
NO GO TO ALT 2D
Residency proof [CHECK AT LEAST ONE] Recent means within 3 months of [MONTH_OF_CERT_DATE] |
Shown during survey |
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Recent utility bill (cableTV, electric/gas, water, sewer, garbage pickup) w/participant name & address |
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Recent rent/mortgage receipt or lease w/participant & address |
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Recent mail (letter and/or postmarked envelope) received w/participant & address |
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Current voter’s registration card w/participant’s name & address |
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[IF STATE ALLOWS] Current driver’s license, State or Tribal ID w/participant’s name and address |
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[OTHER STATE ALLOWED RESIDENCY PROOF] |
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Other: SPECIFY: |
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FI Notes |
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FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE |
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ALT 2B. |
“What is the name of the town, village or pueblo where you live?” |
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Village from WIC records |
Matches Sample Info? |
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Village |
Yes |
No |
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REFUSES
IF VILLAGE NAME GIVEN DOES NOT MATCH SAMPLE INFORMATION, GO TO ALT 2C(i).
IF VILLAGE NAME MATCHES SAMPLE INFORMATION, GO TO ALT 2D.
IF VILLAGE IN SAMPLE INFORMATION IS MISSING, GO TO ALT 2D.
ALT 2C(i). “My records say that you were living in [VILLAGE].
Is there another name for the place you live?”
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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.”
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ALT 2D. MAILING ADDRESS: “What is your current mailing address?”
Mailing address from SAMPLE INFORMATION |
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P.O. Box or Street Address |
P.O. Box NN |
State |
MN |
ZIP |
ZZZZZ |
City |
Anywhere |
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IF MAILING ADDRESS DIFFERENT FROM SAMPLE INFORMATION |
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Gave mailing address |
Yes No |
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City |
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State |
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ZIP |
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IF MAILING ADDRESS MATCHES SAMPLE INFORMATION, GO TO NEXT MODULE.
IF NO MAILING ADDRESS IN SAMPLE INFORMATION OR RELUCTANT TO GIVE MAILING ADDRESS, GO TO NEXT MODULE.
IF MAILING ADDRESS GIVEN DOESN’T MATCH SAMPLE INFORMATION, 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 |
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FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE |
“Next, I’d like to confirm your child’s date of birth. When was [PARTICIPANT] born?”
ENTER DOB: mm/dd/yyyy. READ THE ENTIRE BIRTH DATE BACK TO APPLICANT TO CONFIRM ENTRY.
CAPI WILL CALCULATE THE INFANT OR CHILD’S AGE AS OF CERT_DATE TO DETERMINE WHETHER THE PARTICIPANT CATEGORY IS CORRECT OR ERRONEOUS.
IF THE PARTICIPANT’S CATEGORY = INFANT, THEN THE INFANT CATEGORY IS CORRECT IF A OR B IS TRUE.
THE INFANT MUST BE ≤ 12 MONTHS ON CERT_DATE, OR
THE INFANT’S CERT_DATE FALLS ON OR BETWEEN THE BIRTHDATE + 1 YEAR AND THE LAST DAY OF THE MONTH IN WHICH THE INFANT REACHES 1 YEAR OF AGE +. EXAMPLE:
John Doe was born on April 2, 2016. John Doe has never received WIC before. The most recent certification date was April 10, 2017 and he was certified as an infant, even though he was 12 months, 8 days old. The last day of the month equal to John Doe’s DOB + 1 year is April 30, 2017. CAPI would determine that the participant category was correct. (Although unusual for a WIC agency to certify John Doe as an infant for the remainder of the month, it is technically possible and consistent with WIC regulations.)
IF THE PARTICIPANT’S CATEGORY = CHILD, THEN THE CHILD CATEGORY IS CORRECT IF A OR B OR C IS TRUE:
THE CHILD MUST BE ≤ 60 MONTHS AND > 12 ON CERT_DATE, OR
THE CHILD’S CERT_DATE FALLS ON OR BETWEEN THE BIRTHDATE + 60 MONTHS AND THE LAST DAY OF THE MONTH IN WHICH THE CHILD REACHES 60 MONTHS OF AGE, OR
(NOTE THAT WIC REGULATIONS (246.7(g)(3)) ALLOW LOCALAGENCIES TO SHORTEN OR EXTEND A CURRENT CERTIFICATION PERIOD FOR AN INFANT OR CHILD UP TO 30 DAYS IF THERE IS DIFFICULTY SCHEDULING A CERTIFICATION APPOINTMENT): THE CHILD IS < 12 MONTHS AND THE CERT_DATE FALLS ON OR BETWEEN THE LAST DAY OF THE MONTH IN WHICH THE INFANT TURNS 11 MONTHS OF AGE AND THE BIRTHDATE + 1 YEAR. EXAMPLE:
Jane Doe was born on 12-25-16 and is certified as an infant through 12-31-2017. However, Jane’s mother is having difficulty scheduling a certification appointment for Jane. Her local WIC agency suggests that she come to a certification appointment for Jane on 12-02-17. On that date, the agency certifies Jane as a CHILD even though Jane is 11 months, 7 days old. The agency has discretion to shorten the infant certification period by up to 30 days (i.e., to December 1, 2017) and extend the child certification by this same amount. Jane is less than 12 months of age on her certification date but the certification date is between the last day of the month in which she turns 11 months (November 30) and her first birthday. CAPI would determine that the participant category is correct – no error.
HOUSEHOLD ENUMERATION
“Next, I’m going to ask you to tell me the names of all the people who were living or staying with [NAME OF SAMPLED INFANT/CHILD PARTICIPANT] in [MONTH OF CERT_DATE] and whether they are related or not. I’ll type the names so that I can follow up with some questions. Be sure to include yourself, but please list only people who were living with [SAMPLED INFANT/CHILD] in [MONTH OF CERT_DATE]. Let’s start with [NAME OF INFANT/CHILD] and then with you.”
BEGIN WITH WIC PARTICIPANT (INFANT OR CHILD). RECORD EACH NAME IN THE LIST BELOW. ENTER FIRST NAMES ONLY
PROBE FOR ADDITIONAL PERSONS: Who was living or staying with [NAME OF INFANT/CHILD] in [MONTH OF CERT_DATE]? / Anyone else?
Is [NAME] male or female?
How old is [NAME]?
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 |
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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 |
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21 |
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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. |
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IF ANY Q4= 19 [HOUSEHOLD INCLUDES A FOSTER CHILD WHO SHOULD BE EXCLUDED FROM SAMPLED ECONOMIC UNIT], DISPLAY Q4FOSTER(ii): “When you applied for WIC, did you tell WIC that [NAME OF HOUSEHOLD MEMBER where Q4=19] is a foster child? YES NO
FAMILY MEMBERS TEMPORARILY AWAY
“Other than people already listed, is there anyone who typically lives here but who was temporarily away in [MONTH OF CERT_DATE]? (IF NECESSARY, PROBE: For example, this could be a military service member on active deployment, someone who is in the hospital, in jail or serving time in prison, a child away at school, or a child who lives part-time with each parent. Is there anyone who typically lives here but who was temporarily away?”)
Yes GO TO Q1A (LIST MEMBERS TEMPORARILY AWAY)
No IF STATE EXCLUDES CHILDREN IN TEMPORARY CARE FROM ECONOMIC UNIT:
GO TO CHILDREN IN TEMPORARY CARE OF PARTICIPANT’S FAMILY
IF STATE INCLUDES CHILDREN IN TEMPORARY CARE FROM ECONOMIC UNIT:
GO TO SHARED OR SEPARATE FINANCES
FAMILY MEMBERS TEMPORARILY AWAY=YES
LIST NAME OF EACH PERSON TEMPORARILY AWAY
“Is [NAME] male or female?”
“How old is [NAME]?”
“What is [NAME]’s relationship to [NAME OF INFANT/CHILD]?”
Q4B. “Can you tell me the main reason this person was temporarily away?” DO NOT READ LIST. PROBE FROM LIST IF NECESSARY.
ENTER REASON IN COLUMN Q4B:
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 GO TO Q4C
5=OTHER, SPECIFY (DO NOT LIST ANY PERSON WHO WAS IN JAIL/PRISON IN [MONTH OF CERT_DATE])
IF Q4B=4, CAPI WILL DISPLAY APPROPRIATE 4C QUESTION:
Q4C. IF Q4B=4: “Where does [NAME] live most of the time: READ LIST AND ENTER CODE IN COLUMN Q4C
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
Members temporarily away |
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Q1A |
Q2A |
Q3A |
Q4A |
Relationship Codes |
Q4B |
Q4C |
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NAME |
GENDER |
AGE |
RELATIONSHIP TO INFANT/CHILD |
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 Q4B=4: WHERE CHILD LIVES MOST |
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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 OF THE WIC PARTICIPANT’S FAMILY
“Sometimes, families will take in other children whose parents are temporarily away. Were you or your family providing temporary care to any of the children you’ve listed?” [IF NECESSARY: “I am not referring to your foster child(ren).”] ”
CAPI-FILLED LIST OF CHILDREN ≤14 YEARS OLD NAME |
IN TEMPORARY CARE? |
IF IN TEMPORARY CARE = YES: “Was your family caring temporarily for this child because his/her parents are away on active military deployment? |
“Do you receive any payments from this child’s parents while the child is in your care? If so, how much?” |
||
NAME OF 1st CHILD |
Yes No |
Yes, parents of child on active military deployment No, other reason for temporary care |
Yes No |
$ _____ |
per month per week |
NAME OF 2nd CHILD |
Yes No |
Yes, parents of child on active military deployment No, other reason for temporary care |
Yes No |
$ _____ |
per month per week |
NAME OF 3rd CHILD |
Yes No |
Yes, parents of child on active military deployment No, other reason for temporary care |
Yes No |
$ _____ |
per month per week |
… |
|
|
|
|
|
IF COLUMN 2=YES, IN TEMPORARY CARE, CAPI WILL SET Q4 = 18 FOR THAT CHILD AND EXCLUDE THAT CHILD FROM FAMILY UNIT
SHARED OR SEPARATE FINANCES
CAPI WILL AUTOMATICALLY DISPLAY NAME, GENDER, AGE AND (IF APPLICABLE) REASON TEMPORARILY AWAY OF EACH PERSON. INTERVIEWER WILL READ THE AGE-APPROPRIATE QUESTION AND SELECT RESPONSE IN COLUMN Q6:
“Next, I’m going to ask whether you shared income and expenses with each person who was living with [NAME OF SAMPLED CHILD] in [MONTH OF CERT_DATE].”
IF AGE ≥ 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF CERT_DATE], you were sharing income and expenses as if you were a family – OR do you feel that you each kept your income and expenses and food separate?”
Yes, shared: SELECT “SHARE LIKE FAMILY” FOR NAME
No, kept separate: SELECT “SEPARATE” FOR NAME
IF AGE < 15 YEARS: “Do you consider [NAME] to be part of your family group – that is, in [MONTH OF CERT_DATE], you were responsible for taking care of them as if you were all in the same family?”
Yes, responsible for taking care of: SELECT “SHARE LIKE FAMILY” FOR NAME
No, not responsible for taking care of: SELECT “SEPARATE” FOR NAME
IF NECESSARY FOR MEMBERS TEMPORARILY AWAY, PROBE:
NAME IS ≥ 15 YEARS: “When [NAME] is here, do you and [NAME] share income and expenses?”
NAME IS < 15 YEARS: “When [NAME] is here, do you help take care of [NAME] as if you were all in the same family?”
PREFILLED BY CAPI |
INTERVIEWER SELECTS |
||||
|
Q1 |
Q2 |
Q3 |
Q4B |
Q6 |
|
NAME |
GENDER |
AGE |
REASON TEMPORARILY AWAY |
Family or Separate?1 |
R#. |
name |
(1 or 2) |
(age) |
NA |
1=share like family 2=separate |
R#. |
name |
(1 or 2) |
(age) |
NA |
1=share like family 2=separate |
R#. |
name |
(1 or 2) |
(age) |
NA |
1=share like family 2=separate |
R#. |
name |
(1 or 2) |
(age) |
(1-6 code) |
1=share like family 2=separate |
R#. |
name |
(1 or 2) |
(age) |
(1-6 code) |
1=share like family 2=separate |
PREGNANT FAMILY MEMBERS
P1. “Were you, or was anyone in your household, pregnant at your recent certification appointment at the WIC office?”
Yes GO TO P2
No GO TO Q7 [ADJUNCTIVE ELIGIBILITY]
P2. “Who was pregnant on CERT_DATE?” |
|
<SELECT NAME FROM Q1 LIST DROPDOWN MENU> |
IF PREGNANT MEMBER SHARES FINANCES (Q6=1), GO TO P2A. IF PREGNANTMEMBER HAS SEPARATE FINANCES (Q6=2), GO TO P2D |
P2A. “Were you/Was [NAME] expecting a single infant, twins or multiples?” (DO NOT READ OPTIONS)
SINGLETON IF SHARED FINANCES, CAPI WILL ADD 1 TO FAMILY ECONOMIC UNIT. GO TO P2B
TWINS IF SHARED FINANCES, CAPI WILL ADD 2 TO FAMILY ECONOMIC UNIT. GO TO P2B
MULTIPLES [ENTER NUMBER FROM 3 OR HIGHER] IF SHARED FINANCES, CAPI WILL ADD [N] TO FAMILY ECONOMIC UNIT. GO TO P2B
P2B. “Since that appointment have you/has [NAME] given birth?” (DO NOT READ OPTIONS)
YES GO TO P2C
NO [STILL PREGNANT OR PREGNANCY ENDED] GO TO P2D
P2C. “Have you already listed the infant/infants that you/that [NAME] gave birth to as part of your household above?” [CONFIRM THAT THE SAME NUMBER OF INFANTS FROM PREGNANCY (P2A) ARE ALREADY LISTED IN HOUSEHOLD ENUMERATION CHART] (DO NOT READ OPTIONS)
BE AWARE THAT A “NO” RESPONSE COULD MEAN THAT THE BABY IS DECEASED/WAS STILLBORN, OR DOES NOT LIVE WITH THE PARTICIPANT (ADOPTED OR REMOVED FROM THE HOME BY THE STATE)
YES, WITH [N] BABIES CAPI WILL SUBTRACT [N] FROM FAMILY ECONOMIC UNIT
NO, I/NAME WAS PREGNANT AT THE TIME [LIST INFANT AS A HOUSEHOLD MEMBER]
NO, INFANT DECEASED, REMOVED FROM HOME – DO NOT LIST THE INFANT ANYWHERE CAPI WILL SUBTRACT [N] FROM FAMILY ECONOMIC UNIT
GO TO P2D
P2D. Was anyone else pregnant on CERT_DATE? REPEAT P2-P2D AS NEEDED UNTIL P2D=NO.
YES GO TO P2
NO GO TO Q7 [ADJUNCTIVE ELIGIBILITY]
ADJUNCTIVE OR AUTOMATIC INCOME ELIGIBILITY
IF ADJUNCT_PROGRAM IS KNOWN AND ADJUNCT_ELIG=YES GO TO Q7a
IF ADJUNCT_PROGRAM IS MISSING, AND ADJUNCT_ELIG=YES GO TO Q7b
IF ADJUNCT_ELIG=NO, GO TO Q7c
Q7a. IF ADJUNCT_ELIG=YES AND ADJUNCT_PROGRAM IS KNOWN: “My records show that you qualified for WIC because you, or a member of your family, participates in the [ADJUNCT_PROGRAM]. Can you show me a document to demonstrate participation in that program, such as a dated certification card, award letter or notice of benefits?”
YES ENTER DOCUMENT INFORMATION BELOW IN TABLE
NO GO TO INCOME SOURCES [Note for reviewers:Research team will ask State Agency to look up PARTICIPANT’s enrollment at time of CERT_DATE in a program conferring ADJUNCTIVE ELIGIBILITY]
Documentation: Participation in Program Conferring Adjunctive/Automatic Income Eligibility |
||
Adjunctive program |
|
|
Type of document shown: |
|
|
Name of program participant |
<select name from CAPI-generated list of family EU members> |
|
Start date of eligibility or enrollment |
|
No start date/date unclear PROBE: Do you have anything that shows the dates of your participation? |
Date eligibility or enrollment expires |
|
No expiration date/date unclear PROBE: Do you have anything that shows the dates of your participation? |
Name of agency |
|
Agency name not evident PROBE: Do you have anything that shows the agency name? |
AFTER Q7a, 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]
Q7b. [IF ADJUNCT_PROGRAM IS MISSING, AND ADJUNCT_ELIG=YES] “My records show that you qualified for WIC because you, or a member of your family, participates in a qualifying program such as SNAP, also known as Food Stamps, Temporary Assistance to Needy Families (TANF), sometimes called ‘welfare’ or ‘public assistance’ or a Medicaid program for adults, pregnant women, or children. Were you or anyone in your family receiving SNAP, TANF [PRONOUNCED TAN-if], or Medicaid?”
|
Can you show me a document to demonstrate participation in that program, such as an award letter, notice of benefits, or other document that shows the dates when the [ADJUNCT PROGRAM] participant was eligible?”
YES: ENTER DOCUMENT INFORMATION IN TABLE ABOVE NO: GO TO INCOME SOURCES |
|
“Ok, do you have an award letter, notice of benefits, or other document that shows the dates when the [ADJUNCT PROGRAM] participant was eligible?”
YES: ENTER DOCUMENT INFORMATION IN TABLE ABOVE NO: GO TO INCOME SOURCES |
|
GO TO INCOME SOURCES |
AFTER Q7b, GO TO INCOME SOURCES
Q7c. [IF ADJUNCT_ELIG=NO]: “Were you, or someone in your family, participating in a benefits program such as Medicaid, SNAP, TANF or [NAME OF STATE PROGRAM(S)] on [CERT_DATE]?”
|
PROBE: “Can you show me a document to demonstrate participation in that program, such as an award letter, notice of benefits, or other document that shows the dates when the [ADJUNCT_PROGRAM] participant was eligible?”
YES: ENTER DOCUMENT INFORMATION IN TABLE ABOVE NO: GO TO INCOME SOURCES |
|
PROBE: “Ok, do you have an award letter, notice of benefits, or other document that shows the dates when the [ADJUNCT_PROGRAM] participant was eligible?”
YES: ENTER DOCUMENT INFORMATION IN TABLE ABOVE NO: GO TO INCOME SOURCES |
|
GO TO INCOME SOURCES |
AFTER Q7c, 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 [CERT_DATE], was your family’s income at or below $[INCOME_MAX]?”
|
GO TO Q8a |
|
|
GO TO INCOME SOURCES (Q8a) |
|
INCOME SOURCES
“Now I’m going to ask you about the income received by you and other members of your family. We want to assure you that we will protect your privacy. We will not include information that identifies you or your family in study reports. We will combine the income we collect with information from other people in this study from across the U.S. We will not share personal information about you with your local WIC agency, other benefit programs, your landlord, bank, employer, or people in your community. None of your WIC benefits will change as a result of this survey.”
Q8a. At the time of your most recent certification appointment (on or before [CERT_DATE]), [were you or was anyone in your family] recently unemployed – that is, had been working but stopped?
Yes GO TO Q8b
No GO TO INCOME SOURCES
IF RESPONDENT IS CONFUSED, PROBE: “Had you been working but lost a job or stopped working for some reason?”
Q8b.Who was recently unemployed? |
Q8c. About how long had you[had this person] been unemployed as of CERT_DATE? READ LIST: |
<select name from CAPI-generated list> |
Less than 30 days before CERT_DATE 1 month or longer before CERT_DATE |
<select name from CAPI-generated list> |
Less than 30 days before CERT_DATE 1 month or longer before CERT_DATE |
<select name from CAPI-generated list> |
Less than 30 days before CERT_DATE 1 month or longer before CERT_DATE |
Note to reviewers: If any family member is unemployed, then wages or salary for that family member earned prior to CERT_DATE would be excluded from the countable income.
GO TO Q9A. CAPI WILL DISPLAY QUESTIONS Q9A-Q9E FOR ALL INCOME SOURCES FOR EACH PERSON IN THE FAMILY UNIT WITH SHARED FINANCES WHO IS AGED 15 OR OLDER (CALLED “ADULT FAMILY MEMBER”).
Now I’ll start by asking about your sources of income, and then I’ll ask about sources of income for other members of your family. For each type of income, I may ask to see records or documents showing the dates you received that income and the amount you received. It’s important that we focus on income you or your family members received in the month before your WIC certification appointment on [CERT_DATE].
NOTE FOR REVIEWERS:
On the pages that follow, different types of “proof of income documents” are listed for each income type. The preferred documents appear in underlined text: these documents are those that best meet guidance provided by WIC policy memoranda (#99-4, #2013-3). If a respondent cannot present one of the “preferred” documents, additional acceptable types of proof appear in light gray (non-underlined) text. Each income type also includes an “other” option, where a Field Interviewer may describe another type of document presented as evidence of the income amount reported, and an option to indicate that no documents were available. For each income type, even if documentation is not available, the FI will ask the respondent to report the amount and frequency of that income.
Q9A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ INCOME TYPE IN COLUMN A. CHECK ONLY IF YES.
Q9B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].
9A Income Type |
9B Income Period |
9C Proof of Income Document |
9D Amount |
9E Frequency |
|
|
From: mm/dd/yy To: mm/dd/yy |
Check one, use addtl rows if nec:
|
Gross $
|
|
|
|
From: mm/dd/yy To: mm/dd/yy |
Check one, use addtl rows if nec:
|
Gross $
|
|
|
|
From: mm/dd/yy To: mm/dd/yy |
Check one, use addtl rows if nec:
|
Gross $
|
|
|
A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.
B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].
9A Income Type |
9B Income Period |
9C Proof of Income Document |
9D Amount |
9E Frequency |
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
NET $ |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
NET $ |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
NET $ |
|
|
A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.
B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”].
9A Income Type |
9B Income Period |
9C Proof of Income Document |
9D Amount |
9E Frequency |
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
IF PARTICIPANT/FAMILY MEMBER INDICATES NO INCOME FROM UNEMPLOYMENT COMPENSATION BUT WAS UNEMPLOYED (Q8A), ASK: UE1. “Did you/NAME apply for unemployment benefits?”
UE2. “Was your/NAME’s application denied or approved?” DO NOT READ LIST
UE3. “Okay, you were/NAME was approved to get unemployment, but you have not/NAME has not received any income from unemployment compensation. Can you show me a copy of the approval letter?”
|
|||||
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.
B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]
9A Income Type |
9B Income Period |
9C Proof of Income Document |
9D Amount |
9E Frequency |
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.
B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]
9A Income Type |
9B Income Period |
9C Proof of Income Document |
9D Amount |
9E Frequency |
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.
B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]
9A Income Type |
9B Income Period |
9C Proof of Income Document |
9D Amount |
9E Frequency |
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
A. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [you/NAME] have any income from: READ INCOME TYPE FROM COLUMN A. CHECK ONLY IF YES.
B. Can you show me some evidence of that income such as [READ FIRST ITEM IN COLUMN C. IF FIRST PROOF UNAVAILABLE, READ NEXT ITEM, OR “anything else that would show the amount of this income?” DO NOT READ “NONE”]
9A Income Type |
9B Income Period |
9C Proof of Income Document |
9D Amount |
9E Frequency |
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
|
From: mm/dd/yy To: mm/dd/yy |
|
Gross $
Net pay (check if gross pay unavailable) |
|
|
USING THE SERVICE MEMBER’S MILITARY LEAVE AND EARNINGS STATEMENT, ENTER THE INFORMATION BELOW. SOME PAY CODES WILL PROMPT YOU TO ASK CLARIFYING QUESTIONS THAT WILL AUTOMATICALLY DISPLAY. ANSWERING THE QUESTIONS WILL DETERMINE THE INCOME TREATMENT CODE IN THE RIGHTMOST COLUMN.
Last Name |
First Name |
MI |
Pay Date |
Branch |
Period Covered |
||
|
|
|
|
|
|
||
ENTITLEMENTS |
|
||||||
A |
Type |
Amount |
Income treatment codes |
||||
B |
ENTER PAY CODE |
$ . |
|
||||
C |
ENTER PAY CODE |
$ . |
EXCLUDE: BAH |
||||
D |
ENTER PAY CODE |
$ . |
EXCLUDE: OCONUS COLA |
||||
E |
ENTER PAY CODE |
$ . |
|
||||
F |
ENTER PAY CODE |
$ . |
ANNUALIZE |
||||
G |
ENTER PAY CODE |
$ . |
|
||||
H |
ENTER PAY CODE |
$ . |
|
||||
I |
ENTER PAY CODE |
$ . |
EXCLUDE: COMBAT PAY |
||||
J |
ENTER PAY CODE |
$ . |
|
||||
K |
ENTER PAY CODE |
$ . |
|
||||
L |
ENTER PAY CODE |
$ . |
|
||||
M |
ENTER PAY CODE |
$ . |
|
||||
N |
ENTER PAY CODE |
$ . |
|
||||
O |
ENTER PAY CODE |
$ . |
|
||||
|
REMARKS: ENTER any PAY CODES listed in REMARKS |
$ . |
|
||||
|
TOTAL |
$ . |
Countable income after exclusions and annualizations = |
||||
POSSIBLE LUMP SUM PAYMENT:
“Does [NAME] receive this pay, [PAYCODE], once a year, monthly, or with some other frequency?”
Once per year
Quarterly
Monthly
OTHER: SPECIFY FREQUENCY OR PAY INTERVAL
IF FREQUENCY IS ONCE/YEAR OR QUARTERLY, THEN THE AMOUNT WILL BE ANNUALIZED. OTHERWISE ALL AMOUNTS ARE ASSUMED MONTHLY
POSSIBLE COMBAT PAY:
SELECT YES OR NO FOR EACH QUESTION
|
YES |
NO |
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 WAS COMBAT PAY (AND WILL BE EXCLUDED FROM TOTAL INCOME)
IF NO, TO ANY QUESTION, THE PAY WAS NOT COMBAT PAY AND WILL BE INCLUDED AS INCOME.
Table 3. Military Pay Codes
Code |
Type of Pay |
Counts as Income unless noted otherwise |
AB |
Accession bonus |
Ask Lump Sum |
ACIP |
Aviation Career Incentive Pay |
|
ACP |
Aviation Continuation Pay |
|
AIP |
Assignment Incentive Pay |
Ask Combat Pay |
ASP |
Additional Special Pay |
|
BAH |
Basic Allowance for Housing |
if State excludes, Exclude |
BAS |
Basic Allowance for Subsistence |
|
BAQ |
Basic Allowance for Quarters |
if State excludes, Exclude |
Base Pay |
Base Pay |
|
BCP |
Board Certified Pay Special Pay |
|
CCA |
Civilian Clothing Allowance |
Ask Lump Sum |
BRA |
Basic Replacement Allowance |
Ask Lump Sum |
Continuation Pay |
Continuation Pay |
|
CCCA |
Continuing Civilian Clothing Allowance |
Ask Lump Sum |
CCRA |
Cash Clothing Replacement Allowance |
Ask Lump Sum |
CEFIP |
Career Enlisted Flyer Incentive Pay |
|
CIP |
Combat-related Injury & Rehabilitation |
Ask Combat Pay |
CMA |
Clothing Maintenance Allowance or Clothing Allowance |
|
CONUS COLA |
Continental U.S. Cost of Living Allowance |
Exclude, in-kind benefit |
Combat Duty or Combat Zone Pay |
Combat Duty or Combat Zone Pay |
EXCLUDE |
CRA |
Clothing Replacement Allowance |
Ask Lump Sum |
CSP |
Career Sea Pay |
|
CSP-P |
Career Sea Pay – Premium |
|
CSRB |
Critical Skills Retention Bonus |
Ask Lump Sum |
CVI |
Conditional Voluntary Indefinite Status |
|
DLA |
Dislocation Allowance |
Exclude, in-kind benefit |
Dive Pay |
Dive Pay |
Ask Combat Pay |
DSCT Meal |
Discount Meal |
Exclude, in-kind benefit |
FDP |
Foreign Duty Pay |
Ask Combat Pay |
FLPP |
Foreign Language Proficiency Pay |
Ask Combat Pay |
Flight or Fly Pay |
Flight or Fly Pay |
Ask Combat Pay |
FSA |
Family Separation Allowance |
Ask Combat Pay |
FSH |
Family Separation Housing |
Exclude, in-kind benefit |
FSSA |
Family Subsistence Supplemental Allowance |
EXCLUDE |
HALO |
High Altitude/Low Altitude |
Ask Combat Pay |
HDIP |
Hazardous Duty Incentive Pay |
Ask Combat Pay |
HDP – Involuntary Extension |
Hardship Duty Pay – Involuntary Extension |
Ask Combat Pay |
HDP – L |
Hardship Duty Pay - Location |
Ask Combat Pay |
HDP – M |
Hardship Duty Pay – Mission |
Ask Combat Pay |
HFP/IDP |
Hostile Fire/Imminent Danger Pay |
Ask Combat Pay |
HFP-L |
Hostile Fire Pay - Location |
Ask Combat Pay |
HZD |
Hazardous Duty Pay |
Ask Combat Pay |
ICCA |
Initial Civilian Clothing Allowance |
Ask Lump Sum |
IDP |
Imminent Danger Pay Note: Can also mean Independent Duty Corpsman |
Ask Combat Pay |
ISP |
Incentive Special Pay |
|
Jump Pay |
Jump Pay |
Ask Combat Pay |
LQA |
Living Quarters Allowance |
Exclude, in-kind benefit |
Maternity Clothing Allowance |
Maternity Clothing Allowance |
Ask Lump Sum |
MIHA – Miscellaneous |
Moving Housing Allowance - Miscellaneous |
Exclude, in-kind benefit |
MIHA – Rent |
Moving Housing Allowance – Rent |
Exclude, in-kind benefit |
MIHA – Security |
Moving Housing Allowance - Security |
Exclude, in-kind benefit |
MRB |
Multiyear Retention Bonus |
|
MSP |
Multiyear Special Pay |
|
NIB |
Nuclear Career Annual Incentive Bonus |
|
NPAB |
Nuclear Power Accession Bonus |
Ask Lump Sum |
Nuclear – Continuation Pay |
Nuclear – Continuation Pay |
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OEP |
Overseas Extension Pay |
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OHA |
Overseas Housing Allowance |
Exclude, in-kind benefit |
OCONUS COLA |
Overseas Continental United States Cost of Living Allowance |
if State excludes, Exclude |
OTEIP |
Army Overseas Tour Extension Incentive Pay |
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OVERSEAS COLA |
Overseas Cost of Living Allowance |
Exclude, in-kind benefit |
Overseas Extension Pay |
Overseas Extension Pay |
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PCCA |
Partial Civilian Clothing Allowance |
Ask Lump Sum |
RBMA |
Reserve Basic Maintenance Allowance |
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SBP |
Military Survivor Benefits Plan |
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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 |
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VI |
Voluntary Indefinite Status |
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VBSS Duty |
Maritime Visit, Board, Search & Seizure Duty |
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VSP |
Variable Special Pay |
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ZERO INCOME REPORTED
IF PARTICIPANT DID NOT QUALIFY AS ADJUNCTIVELY/AUTOMATICALLY INCOME ELIGIBILITY FOR WIC AND PARTICIPANT’S TOTAL INCOME = $0 AND NO ADULT ≥ 15 YEARS WAS REPORTED TO HAVE SEPARATE FINANCES (Q6=2), CAPI WILL DISPLAY INTRO AND SKIP TO Z2;
PARTICIPANT DID NOT QUALIFY AS ADJUNCTIVELY/AUTOMATICALLY INCOME ELIGIBILITY FOR WIC AND PARTICIPANT’S TOTAL INCOME = $0 AND IF ANY ADULT AGE ≥ 15 YEARS WAS REPORTED TO HAVE SEPARATE FINANCES (Q6=2), CAPI WILL DISPLAY INTRO AND START WITH Z1
INTRO: “If I understand your answers correctly, it looks like you had zero income on [CERT_DATE].
Z1. You said that [NAME] and [NAME] were not part of your family group. Was/Were [LIST NAMES WHERE Q6=SEPARATE FINANCES], or was anyone that you haven’t named helping you to pay for living expenses such as rent/mortgage, heat, or food on [CERT_DATE]?
Yes GO TO Z1a
No GO TO Z2
Z1a. “In that case, I need to ask you about [NAME]’s income. Thinking back to the 30 days before [CERT_DATE], that is, between [CERT_DATE-30] and [CERT_DATE-1], did [NAME] have any income from [REPEAT Q9a for NAME FOR EACH TYPE OF INCOME SOURCE]. CAPI WILL PROMPT INTERVIEWER TO CHANGE THE RESPONSE TO Q6 FOR [NAME(S)] TO Q6=1 SO THAT THIS INDIVIDUAL IS COUNTED AS PART OF PARTICIPANT’S FAMILY]
AFTER Z1a GO TO END OF SURVEY
Z2. “I’d like to better understand how you were paying for living expenses in [MONTH, YEAR OF CERT_DATE]. Can you tell me if any of the following were true: CHECK ALL THAT APPLY AND ENTER AMOUNT AND DATE IN INCOME SOURCES DOCUMENT FOR RESPONDENT ONLY
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REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, PUBLIC ASSISTANCE |
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REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, WORKER’S COMPENSATION |
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ENTER AMOUNT IN Q9, OTHER CASH |
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IN-KIND BENEFITS NOT INCOME |
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IF ANY INCOME SOURCES RETURN TO Q9 |
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AFTER Z2 GO TO END OF SURVEY
AT ANY TIME WHILE ASKING PARTICIPANT ABOUT INCOME SOURCES (Q9), THE INTERVIEWER MAY BRING UP A LIST OF THE FOLLOWING POTENTIAL LUMP SUM OR INCOME EXCLUSION QUESTIONS:
If participant is a member of an American Indian Tribe and: |
ASK/DO |
Reports income from the government or Tribe |
“Did you receive this income as part of a settlement or agreement between the U.S. government and an American Indian tribe or Nation?” EXCLUDE ANY SUCH INCOME3
“Is this income a ‘per cap’ or per capita payment from a business operated by members of an American Indian tribe or Nation to which you belong?” ENTER NET AMOUNT UNDER ROYALTIES. ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED |
If participant or income document refers to: |
ASK/DO |
Section 8, housing voucher, rental assistance |
“Is this a voucher to help you afford housing or rent?” ANY AMOUNT SHOWN ON A HOUSING CHOICE VOUCHER IS NOT COUNTED AS INCOME. DO NOT ENTER AS AN INCOME SOURCE.4 |
Child care or day care voucher, child care or day care assistance |
EXCLUDE ANY REPORTED PUBLIC ASSISTANCE OR SUBSIDY FOR DAY CARE OR CHILD CARE COSTS5 |
Food Stamps, Free or Reduced Price Lunch or Breakfast for child in public school, WIC food instruments provided to other WIC participants in family |
EXCLUDE ANY REPORTED PUBLIC ASSISTANCE WITH MEALS OR FOOD, INCLUDING ANY REPORT OF FREE MEALS A CHILD RECEIVES AT SCHOOL, FOOD INSTRUMENTS RECEIVED BY ANY FAMILY MEMBER FROM SNAP, FDPIR, OR WIC.6 |
Job assistance, employment training, Employment Services Program, Job Corps, Youth Build, job training, American Job Center, Workforce Investment, Employment Training, Career Pathway |
“Was this income to reimburse you for transportation, child care costs or other expenses so that you could take part in job training, get a GED or take classes that will prepare you for employment?” EXCLUDE REIMBURSEMENTS FOR THESE EXPENSES 7 |
Volunteer, AmeriCorps, VISTA |
“Was this income you received as a volunteer for AmeriCorps, AmeriCorps VISTA or AmeriCorps National Civilian Community Corps (NCCC)?”8 |
Bonus/commissions |
ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED |
Royalties |
ASK “POSSIBLE LUMP SUM” TO DETERMINE IF ANNUALIZATION IS NEEDED |
Any mention of emergency assistance due to a hurricane, tornado, storm, earthquake, volcano, landslide, mudslide, snowstorm, flood, forest fire |
“Did you receive [this] assistance because of a major disaster such as a hurricane, tornado, storm or similar natural event that was declared a federal disaster?” FEMA maintains a list of federal disasters each year: https://www.fema.gov/disasters/grid/year/2015. EXCLUDE ANY ASSISTANCE DUE TO FEDERAL DISASTER FROM INCOME SOURCES9 |
Any mention of loss of property due to flood/hurricane |
“Did this income come from FEMA or the National Flood Insurance Program after filing a claim for flood damage to your home? EXCLUDE ANY INCOME DUE TO APPROVED FLOOD DAMAGE CLAIM10 |
Veteran’s or VA payment, VA disability |
“Did you/NAME receive payment because you were exposed to Agent Orange while serving in Vietnam or Korea?” EXCLUDE ANY AMOUNT DUE TO EXPOSURE TO AGENT ORANGE. INCLUDE ALL OTHER VETERAN’S PAYMENTS11 |
Loan, Student loan |
“Is this income part of a loan that you must repay?” EXCLUDE ANY LOAN AMOUNT FROM INCOME SOURCES unless the loan is an amount to which the participant has constant access (e.g., regular contributions from someone not in the household)12 |
IF PARTICIPANT IS ALSO IN THE SAMPLE FOR THE PROGRAM EXPERIENCES SURVEY:
“Ok, that’s the end of the first part. Here is the first $25 Visa debit card. Next, I’d like to ask about your experiences with the WIC program and your satisfaction with various WIC benefits and services. This next part will take about [ESTIMATED BURDEN OF PROGRAM EXPERIENCE SURVEY] minutes. Afterwards, I’ll give you another $25 card. [GO TO PROGRAM EXPERIENCES SURVEY]
IF PARTICIPANT IS NOT IN THE SAMPLE FOR THE PROGRAM EXPERIENCES SURVEY:
“Ok, this completes our survey. It was great talking with you, and thank you so much for helping us out. Here is a $25 Visa debit card in appreciation for your time.
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 |
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State: |
MN |
City: |
Anytown |
ZIP |
12345 |
Street |
100 MAIN STREET |
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Date |
mm/dd/yy |
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Location was a residential address
Location was a non-residential address (e.g., library, business, community center). PROVIDE NAME OF LOCATION:
Privacy Act Statement
Authority: Code of Federal Regulations. §215.11 requires State and local WIC agency directors to cooperate in the conduct of studies and evaluations.
Purpose: Information is collected primarily for use by the Food and Nutrition Service in the administration and evaluation of Special Supplemental Program for Women, Infants and Children.
Routine Use: FNS published a system of record notice (SORN) titled FNS-8 USDA/FNS Studies and Reports in the Federal Register on April 25, 1991, volume 56, pages 19078-19080, that discusses the terms of protections that will be provided to respondents.
Disclosure: Your participation in this survey is voluntary.
1 Although WIC policy guidance indicates that agencies should determine whether or not separate family economic units have “adequate income” to “sustain the economic unit” and that the “actual living and support costs for the economic unit in that environment must be considered,” the guidance does not indicate how agencies should determine these “actual living and support costs” or what threshold relative to these costs would suffice as “adequate.” Because these judgments are inherently subjective, the NSWP-III cannot independently confirm or disconfirm an independent judgment made by staff at a local WIC agency. If a Participant indicates that a resident of the household maintains separate finances, the NSWP-III will treat those persons as economic unit(s) separate from the participant’s economic unit.
2 See Table 3 for specific military pay codes and proposed exclusions. WIC regulations allow States to choose whether or not to exclude the military Basic Allowance for Housing (BAH) and Cost-of-living allowance for service members stationed outside the contiguous United States (OCONUS COLA) (See 246.7(2)(d)(iv)(A). WIC regulations require States to exclude from income payments to service members from the Family Supplemental Subsistence Act (FSSA) and combat pay. In the context of military pay, WIC Policy Memorandum 2013-3 indicated that “in-kind benefits, such as military on-base housing or other subsidized housing, medical and dental benefits are services that do not meet the definition of ‘income’ and may not be considered in income eligibility determinations.”
3 WIC regulations include income exclusions for multiple types of payments to members of American Indian Tribes from various treaties, agreements or settlements with the U.S. government (see 246.7(2)(d)(iv)(D)(4, 6, 7, 9, 10, 21, 24-32)).
4 WIC regulations include income exclusions for multiple forms of housing assistance to low income individuals (see 246.7(2)(d)(iv)(D)(1, 22-23)
5 WIC regulations include income exclusions for payments, or the value of, child care under the Social Security Act or the Child Care and Development Block Grant programs (see 246.7(2)(d)(iv)(D)(17-19)
6 WIC regulations include income exclusions for the value of food assistance from the National School Lunch Program, the Child Nutrition Act or the Food and Nutrition Act (see 246.7(2)(d)(iv)(D)(8).
7 WIC regulations include income exclusions for payments under the Job Training Partnership Act, replaced by the Workforce Investment Act (WIA) and Workforce Investment and Opportunity Act (WIOA). See 246.7(2)(d)(iv)(D)(5).
8 WIC regulations exclude payments to domestic volunteers (VISTA is now part of AmeriCorps). See 246.7(2)(d)(iv)(D)(2)
9 WIC regulations exclude income from assistance received under the Disaster Relief and Emergency Assistance Amendments of 1989, now the Robert T. Stafford Disaster Relief and Emergency Assistance Act. See 246.7(2)(d)(iv)(D)(13)
10 WIC regulations exclude income from assistance to property owners under the National Flood Insurance Program (246.7(2)(d)(iv)(D)(34).
11 WIC regulations exclude income to certain veterans from the Agent Orange Compensation Exclusion Act ((246.7(2)(d)(iv)(D)(15))
12 WIC regulations exclude loans (246.7(2)(d)(iv)(C)).
pg.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | FINAL |
| Subject | AG-3198-S-15-0040 |
| Author | Joshua Townley |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |