APPENDIX B4.a
DENIED APPLICANT SURVEY VERSION A (ADULT) - ENGLISH
The Denied Applicant 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 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 on-screen 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 |
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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 applicants, establish participant category |
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Determine the size of the applicant’s family economic unit ; Collect documentation of income sources |
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Thank respondent 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 Applicant in the Sample |
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Variable |
Description |
APPLICANT LAST NAME |
Last name of denied WIC applicant |
APPLICANT FIRST NAME |
First name of denied WIC applicant |
STREET |
Street name and number (from WIC agency) |
CITY |
City (from WIC agency) |
STATE |
State (Denied Applicant’s) |
ZIP |
Zipcode |
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 |
APP_DATE |
Date of most recent application (mm/dd/yyyy) |
MONTH OF APP_DATE |
The name of the month of most recent application date (CAPI will calculate from APP_DATE) |
ADJUNCT_ELIG |
IF AVAILABLE FOR DENIED APPLICANT: Yes/No, applicant was adjunctively income eligible for WIC |
ADJUNCT_PROGRAM |
IF AVAILABLE FOR DENIED APPLICANT: Name of program that made ADJUNCT ELIG=yes |
MIGRANT |
Yes/No, applicant is a migrant worker |
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 you think 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. 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 39 minutes (0.65 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.
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 is about identification. Thinking back to [APP_DATE] when you applied for WIC, did you show something with your name and photograph, or some other type of identification?”
YES GO TO 1A
NO GO TO 1B
DON’T RECALL GO TO 1B
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.]
REMEMBERS TYPE SHOWN MARK TYPE IN “ID SHOWN AT WIC” AND GO TO 1E
DON’T RECALL GO TO 1E
Identification proof shown at WIC agency |
Shown at WIC agency (self-reported) |
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Driver’s license w/photo & name |
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State or tribal-issued license or ID w/photo & name |
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U.S. or foreign passport w/photo and name |
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Work, school, military, or bus pass ID w/photo & name |
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WIC ID card or WIC document (;) |
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Letter from government agency (including WIC) w/name |
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Bank statement showing name |
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Utility bill, rent/mortgage receipt, lease, w/name |
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Social Security or Green card (or other Immigration document with name) |
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OTHER: SPECIFY |
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FI Notes |
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1B. “Was there any reason you were unable to show ID when you applied for WIC on APP_DATE?”
DO NOT READ LIST. MULTIPLE RESPONSES OK.
FORGOT TO BRING IT
DIDN’T KNOW WHAT ID TO BRING
THOUGHT I NEEDED DRIVER’S LICENSE, DIDN’T HAVE ONE
DIDN’T HAVE ANY (PROBE: “Why didn’t you have any ID then?”)
ID WAS STOLEN
HOMELESS
LOST MY WALLET/PURSE/ID
LOST ID IN A FIRE, FLOOD, OTHER DISASTER
WAS EVICTED AND LOST MY ID, OTHER PROPERTY
LEFT PARENTS’/PARTNER’S HOME /NO ACCESS TO ID
OTHER (SPECIFY: )
DON’T RECALL/DON’T KNOW
NONE OF THE ABOVE
1C. “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)
NO
1D. “Did you go back to the WIC clinic sometime after [APP_DATE] with identification?
YES GO TO 1E
NO GO TO NEXT MODULE
1E. “Can you show me the same form of identification that you showed WIC, or some other type of ID?”
YES GO TO 1F
NO GO TO NEXT MODULE
1F. DOES NAME ON ID MATCH SAMPLE INFORMATION?
YES MARK TYPE IN “ID SHOWN DURING SURVEY” AND GO TO NEXT MODULE
NO “The name on this ID doesn’t match my records. Can you show me another form of ID that has your name?”
APPLICANT MARRIED, DIVORCED OR OTHER LEGAL NAME CHANGE SINCE APP_DATE
NO VALID IDENTIFICATION GO TO NEXT MODULE
Identification proofs |
ID shown during survey |
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Driver’s license w/photo & name |
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State or tribal-issued license or ID w/photo & name |
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U.S. or foreign passport w/photo and name |
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Work, school, military, or bus pass ID w/photo & name |
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WIC ID card or WIC document (EBT cards are NOT valid proof of identity) |
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Letter from government agency (including WIC) w/name |
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Bank statement showing name |
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Utility bill, rent/mortgage receipt, lease, w/name |
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Social Security or Green card (or other Immigration document with name) |
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OTHER: SPECIFY |
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FI Notes |
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IF APPLICANT OR CAREGIVER LIVES IN REMOTE INDIAN VILLAGE OR PUEBLO THEN CAPI WILL SKIP TO “ALTERNATE PROOF OF RESIDENCY.” ELSE CAPI WILL 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 you to show something with your name and home address to prove where you live?”
YES GO TO 2A
NO GO TO 2B
DON’T RECALL GO TO 2B
2A. “What did you show that had your home address?”
REMEMBERS PROOF SHOWN MARK IN “SHOWN AT WIC” BELOW AND GO TO 2E
DON’T RECALL GO TO 2E
Residency proofs |
Shown at WIC appointment (self-reported) |
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Utility bill (cableTV, electric/gas, water, sewer, garbage pickup) w/applicant name & address |
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Rent/mortgage receipt or lease w/applicant name & address |
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Mail (letter and/or postmarked envelope) received w/applicant name & address |
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Voter’s registration card w/applicant name & address |
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[IF STATE ALLOWS] Driver’s license, State or Tribal ID w/applicant 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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2B. “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. MULTIPLE RESPONSES OK.
FORGOT TO BRING IT
DIDN’T KNOW WHAT TO BRING
THOUGHT I NEEDED DRIVER’S LICENSE, DIDN’T HAVE ONE
DIDN’T HAVE ANY (PROBE: “Why didn’t you have any proof of your address then?”)
WAS STOLEN
HOMELESS
LOST MY WALLET/PURSE/ID
LOST IN A FIRE, FLOOD, OTHER DISASTER
WAS EVICTED AND LOST MY BELONGINGS
LEFT PARENTS’/PARTNER’S HOME /NO ACCESS TO PROOF
OTHER (SPECIFY: )
DON’T RECALL/DON’T KNOW
NONE OF THE ABOVE
2C. IF ITEM 1C WAS ADMINISTERED, GO TO 2D. OTHERWISE ASK:
“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 2D
NO GO TO 2D
2D. “Did you go back to the WIC clinic sometime after [APP_DATE] with something proving where you lived?
YES GO TO 2E
NO GO TO NEXT MODULE
2E. “Can you show me that same document or something else with your name and home address now [IF NECESSARY: such as a utility bill, lease, or letter with your name and address?”]
[IF RESPONDENT HAS TROUBLE WITH THIS REQUEST, READ 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.
YES GO TO 2F
NO GO TO NEXT MODULE
2F. DO NAME AND ADDRESS MATCH SAMPLE INFORMATION?
YES MARK PROOF SHOWN DURING SURVEY AND GO TO NEXT MODULE
NAME IS DIFFERENT BUT ADDRESS MATCHES GO TO 2G
NAME MATCHES BUT ADDRESS IS DIFFERENT GO TO 2H
NAME AND ADDRESS ARE BOTH DIFFERENT GO TO 2H
Residency proofs [CHECK AT LEAST ONE] |
Shown during survey |
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Utility bill (cableTV, electric/gas, water, sewer, garbage pickup) w/applicant name & address |
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Rent/mortgage receipt or lease w/applicant & address |
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Mail (letter and/or postmarked envelope) received w/applicant & address |
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Voter’s registration card w/applicant’s name & address |
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[IF STATE ALLOWS] Current driver’s license, State or Tribal ID w/applicant’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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2G. (NAME IS DIFFERENT BUT ADDRESS MATCHES): “This has an address, but someone else’s name. Do you have something with your name and address?”
YES MARK PROOF SHOWN DURING SURVEY AND GO TO NEXT MODULE
ADDRESS MATCHES BUT APPLICANT MARRIED, DIVORCED OR OTHER LEGAL NAME CHANGE SINCE APP_DATE:
GO TO NEXT MODULE
ADDRESS IS DIFFERENT BUT NAME MATCHES GO TO 2H
NAME AND ADDRESS ARE BOTH DIFFERENT GO TO 2H
NO CURRENT PROOF OF RESIDENCY GO TO NEXT MODULE
2H. (ADDRESS DIFFERS OR NAME AND ADDRESS DIFFER): “Ok, the [name and] address on this document doesn’t match my records. Have you moved since APP_DATE?”
YES (RECENTLY MOVED) ENTER INFO BELOW AND GO TO NEXT MODULE
NO (DID NOT RECENTLY MOVE) GO TO 2I
State: |
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ZIP: |
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ADDRESS IS A STREET ADDRESS (Not PO Box)? |
Yes No |
2I. “Do you have something with your name and home address such as a utility bill, lease, or something that was recently mailed to you?”
YES REVERSE TO 2F
NO GO TO NEXT MODULE
ALTERNATE PROCEDURE APPLIES ONLY IF APPLICANT LIVES ON TRIBAL LAND OR IN REMOTE INDIAN VILLAGE OR PUEBLO. ELSE USE RESIDENCY: GEOGRAPHIC STATES.
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 DOES 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. “When you applied for WIC in [MONTH_OF_APP_DATE], did you show a document with your 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] |
Shown during survey |
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Utility bill (cable TV, electric/gas, water, sewer, garbage pickup) w/applicant name & address |
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Rent/mortgage receipt or lease w/applicant & address |
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Mail (letter and/or postmarked envelope) received w/applicant & address |
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Voter’s registration card w/applicant’s name & address |
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[IF STATE ALLOWS] Driver’s license, State or Tribal ID w/applicant’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 Sample Information: [VILLAGE] |
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.
IF VILLAGE NAME MATCHES SAMPLE INFORMATION, GO TO ALT 2D.
IF VILLAGE IN SAMPLE INFORMATION is missing, GO TO ALT 2D
IF APPLICANT RELUCTANT TO GIVE VILLAGE NAME, GO TO ALT 2D.
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?
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ALT 2C (ii)
(ii) Did you recently move?”
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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 IF 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?”
YES GO TO NEXT MODULE
NO GO TO NEXT MODULE
FI Notes |
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FI: TYPE ANY CLARIFICATIONS OR EXPLANATORY NOTES HERE |
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 (that is, I 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 PREGNANT AND RECENT BIRTH GO TO 3A
5=BOTH PREGNANT AND RECENT PREGNANCY ENDED GO TO 3A
6=BOTH RECENT BIRTH AND RECENT PREGNANCY ENDED GO TO 3B
7= PREGNANT, RECENT BIRTH AND RECENT PREGNANCY ENDED GO TO 3A
8=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?”
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SKIP TO NEXT INCOME ELIGIBILITY MODULE |
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IF Q3=1 SKIP TO INCOME ELIGIBILITY MODULE IF Q3=4 GO TO 3B IF Q3=5 GO TO 3C IF Q3=7 GO TO 3B |
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SKIP TO NEXT INCOME ELIGIBILITY |
3B. “When was your baby born?”
ENTER DATE OF BIRTH: |
mm-dd-yyyy |
CAPI WILL DETERMINE INFANT AGE ON APP_DATE. |
GO TO 3D.
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 |
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IF UNSURE OF DATE, “Ok, which of the following is your best guess for when your pregnancy ended:” READ LIST |
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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/WEEKS] 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
3FA. Ok, I need to know which happened first, you gave birth or you had a recent pregnancy end.
[FI: PROMPT FOR DATE OF BIRTH; IF DATE OF END OF PREGNANCY NOT KNOWN, ASK WHICH HAPPENED FIRST]
(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 OR:
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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.” |
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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 1ST 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 1ST 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 1ST BIRTHDAY, CHECK DATE_PREG_END (this WIC applicant 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 6TH 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 6TH 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
HOUSEHOLD ENUMERATION
“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].”
BEGIN WITH WIC APPLICANT FIRST. RECORD EACH NAME IN THE LIST BELOW. ENTER FIRST NAME ONLY.
Who was living or staying with you in [MONTH OF APP_DATE]? PROBE FOR ADDITIONAL PERSONS: Anyone else?
Is [NAME] male or female?
How old is [NAME]?
What is [NAME]’s relationship to you?
Q1 |
Q2 |
Q3 |
Q4 |
Relationship Codes |
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NAME |
GENDER 1=male 2=female |
AGE in years |
RELATIONSHIP to WIC Applicant |
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 |
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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/are a foster child/ren? YES NO
FAMILY MEMBERS TEMPORARILY AWAY
“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 Q1A (MEMBERS TEMPORARILY AWAY)
No IF STATE EXCLUDES CHILDREN IN TEMPORARY CARE FROM ECONOMIC UNIT:
GO TO CHILDREN IN TEMPORARY CARE OF APPLICANT’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 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. 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 APP_DATE]
IF Q4B=4, CAPI WILL DISPLAY APPROPRIATE 4C QUESTION:
Q4C. IF Q4B=4: “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
Members temporarily away |
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Q1A |
Q2A |
Q3A |
Q4A |
Relationship Codes |
Q4B |
Q4C |
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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 (1-5) |
If Q4B=4: WHERE CHILD LIVES MOST |
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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 OF THE DENIED APPLICANT’S FAMILY
“Sometimes, families will take in other children whose parents are temporarily away. Thinking back to [MONTH OF APP_DATE], 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 |
IN TEMPORARY CARE? |
IF IN TEMPORARY CARE = YES: “Was your family caring temporarily for this child because his/her parents were away on active military deployment? |
“Did you receive any payments from this child’s parents while the child was 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 ECONOMIC 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 here in [MONTH OF APP_DATE].”
IF AGE OF HOUSEHOLD MEMBER≥ 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, shared: SELECT “SHARE LIKE FAMILY” FOR NAME
No, kept separate: SELECT “SEPARATE” FOR NAME
Don’t recall SELECT “SHARE LIKE FAMILY” FOR NAME
IF AGE OF HOUSEHOLD MEMBER < 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
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?”
PREFILLED |
INTERVIEWER SELECTS |
||||
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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) |
(1-5 code) |
1=share like family 2=separate |
R#. |
name |
(1 or 2) |
(age) |
(1-5 code) |
1=share like family 2=separate |
PREGNANT FAMILY MEMBERS
IF PARTICIPANT CATEGORY ITEM Q3=(1, 4, 5, or 7) CAPI WILL DISPLAY P1-P1B, OTHERWISE CAPI WILL SKIP 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 IF SHARED FINANCES CAPI WILL ADD 1 TO FAMILY ECONOMIC UNIT
Twins IF SHARED FINANCES CAPI WILL ADD 2 TO FAMILY ECONOMIC UNIT
More than twins: ENTER NUMBER (TRIPLETS =3, QUADRUPLETS =4, ETC) IF SHARED FINANCES 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)
BE AWARE THAT A “NO” RESPONSE COULD MEAN THAT THE BABY IS DECEASED/WAS STILLBORN, OR DOES NOT LIVE WITH THE APPLICANT (ADOPTED OR REMOVED FROM THE HOME BY THE STATE)
YES, WITH [N] BABIES LISTED CAPI WILL SUBTRACT [N] FROM FAMILY ECONOMIC UNIT
NO, INFANT DECEASED, REMOVED FROM HOME, WAS NOT LIVING IN HOUSEHOLD ON APP_DATE – DO NOT LIST THE INFANT ANYWHERE
P2. “Was anyone/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 Q7, ADJUNCTIVE ELIGIBILITY
P3. “Who was pregnant on APP_DATE?” |
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<SELECT NAME FROM Q1 LIST DROPDOWN MENU> |
IF PREGNANT MEMBER SHARES FINANCES (Q6=1), GO TO P3A. IF PREGNANT MEMBER HAS SEPARATE FINANCES (Q6=2), GO TO P3D |
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
More than twins: 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)
BE AWARE THAT A “NO” RESPONSE COULD MEAN THAT THE BABY IS DECEASED/WAS STILLBORN, OR DOES NOT LIVE WITH THE APPLICANT (ADOPTED OR REMOVED FROM THE HOME BY THE STATE)
YES, WITH [N] BABIES LISTED CAPI WILL SUBTRACT [N] FROM FAMILY ECONOMIC UNIT
NO: [NAME] WAS PREGNANT AT THE TIME [LIST INFANT AS A HOUSEHOLD MEMBER]
NO: INFANT DECEASED, REMOVED FROM HOME, WAS NOT LIVING IN HOUSEHOLD ON APP_DATE – DO NOT LIST THE INFANT ANYWHERE
P3D. “Was anyone else pregnant on APP_DATE?”
YES IF YES, REVERSE TO P3 AND REPEAT P3-P3D AS NEEDED
NO GO TO Q7, ADJUNCTIVE ELIGIBILITY
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 [OR STATE-SPECIFIC NAME OF MEDICAID PROGRAM(S)], SNAP, TANF or [NAME OF STATE PROGRAM(S)]?”
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“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?” |
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“Ok, do you have an award letter, notice of benefits, or other document that shows the dates when the [ADJUNCT_PROGRAM] participant was eligible?” |
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GO TO INCOME SOURCES |
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GO TO INCOME SOURCES |
IF RESPONDENT HAS DOCUMENTATION, ENTER INFORMATION IN TABLE BELOW
Documentation: Participation in Program Conferring Adjunctive/Automatic Income Eligibility |
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Adjunctive program |
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Type of document shown: |
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Name of program participant |
<select name from CAPI-generated list of family EU members> |
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Start date of eligibility or enrollment |
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No start date/date unclear PROBE: Do you have anything that shows the dates of your participation? |
Date eligibility or enrollment expires |
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No expiration date/date unclear PROBE: Do you have anything that shows the dates of your participation? |
Name of agency |
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Agency name not evident PROBE: Do you have anything that shows the agency name? |
IF FIRST DATE OF ELIGIBILITY ON DOCUMENT IS MORE RECENT THAN APP_DATE, GO TO “PROOF TOO NEW.”
IF LAST DATE OF ELIGIBILITY OCCURRED BEFORE APP_DATE, GO TO “PROOF EXPIRED.”
IF NO PROOF, OR INFORMATION FROM DOCUMENT ENTERED, GO TO “OTHER BENEFITS PROGRAM.”
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 ENTER INFORMATION FROM CORRECTLY DATED PROOF OF PARTICIPATION IN ADJUNCT PROGRAM (CAPI WILL PRESENT A NEW TABLE FOR ENTERING INFORMATION FROM THE NEXT DOCUMENT SHOWN)
NO GO TO OTHER BENEFITS PROGRAM
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 ENTER INFORMATION FROM CORRECTLY DATED PROOF OF PARTICIPATION IN ADJUNCT PROGRAM(CAPI WILL PRESENT A NEW TABLE FOR ENTERING INFORMATION FROM THE NEXT DOCUMENT SHOWN)
NO GO TO OTHER BENEFITS PROGRAM
OTHER BENEFITS PROGRAM
“Was anyone in your family 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 CAPI WILL REPEAT RESPONSE OPTIONS AND PROMPTS SHOWN ABOVE UNDER Q7 FOR FI TO ENTER INFORMATION ABOUT PARTICIPATION IN ANY OTHER PROGRAM THAT MAY CONFER ADJUNCTIVE INCOME ELIGIBILITY
NO “OK, thank you. Let’s move on to income sources.” GO TO INCOME SOURCES
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]
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]?”
|
GO TO ID8A |
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GO TO INCOME SOURCES (Q8a) |
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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]. 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 won’t share personal information about you with your local WIC agency, other benefit programs, your landlord, bank, employer, or people in your community.”
Q8a. At the time you applied for WIC on [APP_DATE], were you or was anyone in your family unemployed – that is, had been working but stopped?
Yes GO TO Q8b
No GO TO INCOME SOURCES
IF RESPONDENT IS CONFUSED, PROBE: “Had you (or someone in your family) been working but lost a job or stopped working for some reason?”
Q8b.Who was unemployed then? |
Q8c. About how long had you [had this person] been unemployed as of APP_DATE? READ LIST: |
<select name from CAPI-generated list> |
Less than 30 days before APP_DATE 1 month or longer before APP_DATE |
<select name from CAPI-generated list> |
Less than 30 days before APP_DATE 1 month or longer before APP_DATE |
<select name from CAPI-generated list> |
Less than 30 days before APP_DATE 1 month or longer before APP_DATE |
“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 were receiving at the time you applied for WIC in [MONTH_OF_APP_DATE].”
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”).
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 [APP_DATE], 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 9C. 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 |
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From: mm/dd/yy To: mm/dd/yy |
Check one, use addtl rows if nec:
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Gross $
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From: mm/dd/yy To: mm/dd/yy |
Check one, use addtl rows if nec:
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Gross $
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From: mm/dd/yy To: mm/dd/yy |
Check one, use addtl rows if nec:
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Gross $
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A. Thinking back to the 30 days before [APP_DATE], 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 |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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NET $ |
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From: mm/dd/yy To: mm/dd/yy |
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NET $ |
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From: mm/dd/yy To: mm/dd/yy |
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NET $ |
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A. Thinking back to the 30 days before [APP_DATE], 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 |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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IF APPLICANT/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?”
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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A. Thinking back to the 30 days before [APP_DATE], 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 |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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A. Thinking back to the 30 days before [APP_DATE], 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 |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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A. Thinking back to the 30 days before [APP_DATE], 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 |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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A. Thinking back to the 30 days before [APP_DATE], 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 |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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From: mm/dd/yy To: mm/dd/yy |
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Gross $
Net pay (check if gross pay unavailable) |
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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 |
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ENTITLEMENTS |
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A |
Type |
Amount |
Income treatment codes |
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B |
ENTER PAY CODE |
$ . |
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C |
ENTER PAY CODE |
$ . |
EXCLUDE: BAH |
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D |
ENTER PAY CODE |
$ . |
EXCLUDE: OCONUS COLA |
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E |
ENTER PAY CODE |
$ . |
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F |
ENTER PAY CODE |
$ . |
ANNUALIZE |
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G |
ENTER PAY CODE |
$ . |
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H |
ENTER PAY CODE |
$ . |
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I |
ENTER PAY CODE |
$ . |
EXCLUDE: COMBAT PAY |
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J |
ENTER PAY CODE |
$ . |
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K |
ENTER PAY CODE |
$ . |
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L |
ENTER PAY CODE |
$ . |
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M |
ENTER PAY CODE |
$ . |
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N |
ENTER PAY CODE |
$ . |
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O |
ENTER PAY CODE |
$ . |
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REMARKS: ENTER any PAY CODES listed in REMARKS |
$ . |
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TOTAL |
$ . |
Countable income after exclusions and annualizations = |
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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
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YES |
NO |
Did [NAME] receive this pay in addition to the base pay? |
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Was this pay the result of deployment to a designated combat zone? |
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Did [NAME] only receive this pay while deployed to the combat zone? |
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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 |
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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 |
|
ZERO INCOME REPORTED [TOTAL INCOME=$0]
IF APPLICANT DID NOT CLAIM PARTICIPATION IN MEDICAID, SNAP AND/OR TANF; AND IF APPLICANT’S TOTAL FAMILY INCOME =$0; AND IF NO ADULT AGED ≥ 15 WAS REPORTED TO HAVE SEPARATE FINANCES, CAPI WILL DISPLAY INTRO AND Z2.
IF APPLICANT DID NOT CLAIM PARTICIPATION IN MEDICAID, SNAP AND/OR TANF; AND IF APPLICANT’S TOTAL FAMILY INCOME =$0; AND IF ANY ADULT AGED ≥ 15 WAS REPORTED TO HAVE SEPARATE FINANCES, CAPI WILL DISPLAY INTRO AND START WITH Z1.
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 Z2
Z1a. “In that case, I need to ask you about [NAME]’s income. Thinking back to the 30 days before [APP_DATE], did [NAME] have any income from [LIST EACH TYPE OF INCOME SOURCE FROM Q9A]? 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 APPLICANT’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 APP_DATE]. Can you tell me if any of the following were true: CHECK ALL THAT APPLY.
|
REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, PUBLIC ASSISTANCE |
|
REQUEST AWARD LETTER AND ENTER AMOUNT AND DATE IN Q9, WORKER’S COMPENSATION. |
|
ENTER AMOUNT IN Q9, OTHER CASH |
|
|
|
IN-KIND BENEFITS NOT INCOME |
|
IF ANY INCOME SOURCES RETURN TO Q9 |
|
|
AFTER Z2 GO TO END OF SURVEY
AT ANY TIME WHILE ASKING APPLICANT 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 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 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.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 applicant has constant access (e.g., regular contributions from someone not in the household)13 |
“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 study respondent 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 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)).
pg.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | DRAFT |
| Subject | AG-3198-S-15-0040 |
| Author | Joshua Townley |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |